Cost and utilization of healthcare services for hip and knee replacement

The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes: An Observational Study

BACKGROUND

A preoperative medical evaluation (PME) in total joint arthroplasty (TJA) is routine despite considerable variation and uncertainty regarding its benefits. The orthopaedic department in our academic health system established a perioperative medical clinic (PMC) to standardize perioperative management and to study the effect of this intervention on total hip arthroplasty (THA) and total knee arthroplasty (TKA) outcomes. This observational study compared the impact of a PME within 30 days prior to surgery at the PMC (Periop30) versus elsewhere ("Usual Care") on postoperative length of stay (LOS), extended LOS (i.e., a stay of >3 days), and Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10) Global Physical Health (GPH) score improvement in TJA.

METHODS

We stratified adult patients (≥18 years of age) who underwent primary TJA between January 2015 and December 2020 into Periop30 or Usual Care. We utilized univariate tests (a chi-square test for categorical variables and a t test for continuous variables) to assess for differences in patient characteristics. For both TKA and THA, LOS was assessed with use of multivariable negative binomial regression models; extended LOS, with use of binary logistic regression; and PROMIS-10 GPH score, with use of mixed-effects models with random intercept and slope. Interaction terms between the focal predictor (Periop30, yes or no) and year of surgery were included in all models.

RESULTS

Periop30 comprised 82.3% of TKAs (1,911 of 2,322 ) and 73.8% of THAs (1,876 of 2,541). For THA, the Periop30 group tended to be male (p = 0.005) and had a higher body mass index (p = 0.001) than the Usual Care group. The Periop30 group had a higher rate of staged bilateral THA (10.6% versus 7.5%; p = 0.028) and a lower rate of simultaneous bilateral TKA (5.1% versus 12.2%; p < 0.001) than the Usual Care group. Periop30 was associated with a lower mean LOS for both TKA (43.46 versus 54.15 hours; p < 0.001) and THA (41.07 versus 57.94 hours; p < 0.001). The rate of extended LOS was lower in the Periop30 group than in the Usual Care group for both TKA (15% versus 26.5%; p < 0.001) and THA (13.3% versus 27.4%; p < 0.001). There was no significant difference in GPH score improvement between Periop30 and Usual Care for either TKA or THA.

CONCLUSIONS

Periop30 decreased mean LOS and the rate of extended LOS for TJA without an adverse effect on PROMIS-10 GPH scores.

LEVEL OF EVIDENCE

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

Quality indicators in primary elective total hip and knee arthroplasty

PURPOSE

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent a significant portion of healthcare spending and are high-priority for quality improvement initiatives. This study aims to develop quality indicators (QIs) in the care of primary elective THA and TKA patients. These QIs serve a number of purposes including documentation of the quality of care, objective comparisons of institutions/providers, facilitating pay-for-performance initiatives, and supporting accountability, regulation, and accreditation.

METHODS

A guideline-based approach, initially described by Kötter et al., was utilized. Eight clinical practice guidelines (CPGs) were evaluated for candidate indicators (CIs). CIs with high-quality evidence and consensus statements were extracted. Eighteen additional CIs were included from previous work that evaluated quality improvement databases. Each CI and supporting evidence was submitted for independent review by an expert panel. The RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology was utilized and items were rated based on validity, reliability, and feasibility of measurement. After two rounds of ratings and ranking, a final ranked list of QIs was obtained.

RESULTS

Fifty-six CIs were identified from the literature and CPGs or proposed by the expert panel. Two rounds of voting resulted in 12 total QIs that were deemed appropriate measures of high-quality care. The final 12 QIs were ranked by order of importance: use of peri-operative tranexamic acid, infusion of prophylactic antibiotics prior to inflation of tourniquet, appropriate post-operative venous thromboembolic prophylaxis, complication rate, rate of secondary procedure, readmission rate, early mobilization, average change of pre- to one year post-operative functional status, use of multimodal analgesia, use of neuraxial anesthesia, use of peri-articular injection in TKA, and use of pre-operative PO analgesia.

CONCLUSION

This study is an expert opinion based on parameters observed in modern and high-quality academic settings. Twelve QIs are proposed to assess the quality of care in the peri-operative management of primary elective THA and TKA patients.

Robotic-Arm Assisted Technology's Impact on Knee Arthroplasty and Associated Healthcare Costs

Background: The number of total knee arthroplasties (TKA) carried out globally is expected to substantially rise in the coming decades. Consequently, focus has been increasing on improving surgical techniques and minimizing expenses. Robotic arm-assisted knee arthroplasty has garnered interest to reduce surgical errors and improve precision. Objectives: Our primary aim was to compare the episode-of-care cost up to 90 days for unicompartmental knee arthroplasty (UKA) and TKA performed before and after the introduction of robotic arm-assisted technology. The secondary aim was to compare the volume of UKA vs TKA. Methods: This was a retrospective study design at a single healthcare system. For the cost analysis, we excluded patients with bilateral knee arthroplasty, body mass index >40, postoperative infection, or noninstitutional health plan insurance. Costs were obtained through an integrated billing system and affiliated institutional insurance company. Results: Knee arthroplasty volume increased 28% after the introduction of robotic-assisted technology. The TKA volume increased by 17%, while the UKA volume increased 190%. Post introduction, 97% of UKA cases used robotic arm-assisted technology. The cost analysis included 178 patients (manual UKA, n = 6; robotic UKA, n = 19; manual TKA, n = 58, robotic TKA, n = 85). Robotic arm-assisted TKA and UKA were less costly in terms of patient room and operating room costs but had higher imaging, recovery room, anesthesia, and supply costs. Overall, the perioperative costs were higher for robotic UKA and TKA. Postoperative costs were lower for robotic arm-assisted surgeries, and patients used less home health and home rehabilitation. Discussion: Surgeons performed higher volumes of UKA, and UKA comprised a greater percentage of total surgical volume after the introduction of this technology. The selective cost analysis indicated robotic arm-assisted technology is less expensive in several cost categories but overall more expensive by up to $550 due to higher cost categories including supplies and recovery room. Conclusions: Our findings show a change in surgeons' practice to include increased incidence and volume of UKA procedures and highlights several cost-saving categories through the use of robotic arm-assisted technology. Overall, robotic arm-assisted knee arthroplasty cost more than manual techniques at our institution. This analysis will help optimize costs in the future.

Bundled Payment Plans Are Associated With Notable Cost Savings for Ambulatory Outpatient Total Shoulder Arthroplasty

INTRODUCTION

Bundling of services, typically into a 90-day episode of care, is intended to facilitate cost reduction. The purpose of this study was to determine the impact of a private insurance bundling program on the costs of outpatient total shoulder arthroplasty (TSA) at a freestanding ambulatory surgery center.

METHODS

A cost minimization analysis was done of patients who had anatomic TSA by a single surgeon at a single freestanding ambulatory surgery center, including line-by-line comparisons of demographic and comorbidity factors for all patients treated within the 90-day episode of care.

RESULTS

Seventy-six primary anatomic TSAs were included, 39 in the bundled group and 37 outside of the program. The bundled group was on average older (58 years) than the unbundled group (54 years, P = 0.021), but the groups were otherwise similar in demographics. The average total implant charges were significantly less for the bundled group ($24,822.43 versus $28,405.51, P = 0.014). Average total surgery supply charges and anesthesia supply charges were similar (P > 0.05). Mean total outpatient surgical day charges (implants, surgical, and anesthesia equipment) were significantly less for the bundled group ($29,782.43 versus $33,238.68, P = 0.022), as were average operating room staffing costs ($135.37 versus $162.55, P = 0.015). During the 90-day postoperative period, charges were similar.

CONCLUSIONS

Primary anatomic TSA using a bundled care program in an outpatient setting coincides with markedly lower charges. The primary driver of this reduction is implant pricing, which is negotiated as part of the bundle. Surgeons must carefully analyze their unique practices in the changing economic health care environment when creating an outpatient TSA and/or bundling program.

LEVEL OF EVIDENCE

Level III economic analysis.

Model of Short- and Long-Term Outcomes of Emicizumab Prophylaxis Treatment for Persons with Hemophilia A

BACKGROUND

Hemophilia A (HA) can result in bleeding events because of low or absent clotting factor VIII (FVIII). Prophylactic treatment for severe HA includes replacement FVIII infusions and emicizumab, a bispecific factor IXa- and factor X-directed antibody.

OBJECTIVE

To develop an economic model to predict the short- and long-term clinical and economic outcomes of prophylaxis with emicizumab versus short-acting recombinant FVIII among persons with HA in the United States.

METHODS

A Markov model was developed to compare clinical outcomes and costs of emicizumab versus FVIII prophylaxis among persons with severe HA from U.S. payer and societal perspectives. Patients started prophylaxis at age 1 year in the base case. Mutually exclusive health states considered were "no arthropathy," "arthropathy," "surgery," and "death." Serious adverse events, breakthrough bleeds, and inhibitor development were simulated throughout the modeled time horizon. In addition to the prophylaxis drug costs, patients could incur other direct costs related to breakthrough bleeds treatment, serious adverse events, development of inhibitors, arthropathy, and orthopedic surgery. Indirect costs associated with productivity loss (i.e., missed work or disabilities) were applied for adults. Model inputs were obtained from the HAVEN 3 trial, published literature, and expert opinion. The model used a lifetime horizon, and results for 1 year and 5 years were also reported. Deterministic sensitivity analyses and scenario analyses were conducted to assess robustness of the model.

RESULTS

Over a lifetime horizon, the cumulative number of all treated bleeds and joint bleeds avoided on emicizumab versus FVIII prophylaxis were 278.2 and 151.7, respectively. Correspondingly, arthropathy (mean age at onset: 12.9 vs. 5.4 years) and FVIII inhibitor development (mean age at development: 13.9 vs. 1.1 years) were delayed. Total direct and indirect costs were lower for emicizumab versus FVIII prophylaxis for all modeled time horizons ($97,159 vs. $331,610 at 1 year; $603,146 vs. $1,459,496 at 5 years; and $15,238,072 vs. $22,820,281 over a lifetime horizon). The sensitivity analyses indicated that clinical outcomes were sensitive to efficacy inputs, while economic outcomes were driven by the discount rate, dosing schedules, and treatments after inhibitor development. Results for moderate to severe patients were consistent with findings in the severe HA population.

CONCLUSIONS

The model suggests that emicizumab prophylaxis confers additional clinical benefits, resulting in a lower number of bleeding events and delayed onset of arthropathy and inhibitor development across all time assessment horizons. Compared with short-acting recombinant FVIII, emicizumab prophylaxis leads to superior patient outcomes and cost savings from U.S. payer and societal perspectives.

DISCLOSURES

Funding for this study was provided by Genentech. Raimundo and Patel are employees of Genentech and own stock or stock options. Zhou, Han, Ji, Fang, Zhong, and Betts are employees of Analysis Group, which received consultancy fees from Genentech for conducting this study. Mahajerin received consultancy fees from Genentech for work on this study. Portions of this research were presented as a poster at the 2018 American Society of Hematology Conference; December 1-4, 2018; San Diego, CA.

Do More Expensive Total Knee Arthroplasty Prostheses Provide Greater Improvements in Outcomes Over Less Expensive Prostheses Sold by a Physician-owned Distributorship?

BACKGROUND

It is unknown whether more expensive total knee prostheses provide better improvements in patient-determined outcomes compared with less expensive prostheses. A physician-owned distributorship (POD) was created with a goal to provide lower cost implants to hospitals as an alternative to higher cost prostheses sold by the large orthopaedic implant companies. The hypothesis was that lower cost total knee prostheses would have equivalent outcomes, while resulting in lower costs to the hospitals purchasing them compared with higher cost industry-supplied knee prostheses.

METHODS

From May 2013 until January 2015, a POD existed which included five surgeons that performed total knee arthroplasties and were willing to follow the outcomes to ensure quality. The POD sold two knee arthroplasty systems at a cost that was lower than that of the large industry companies. Surgeons were allowed to use either POD knees or industry knees at their own discretion. Patients were followed up prospectively to determine The Knee Injury and Osteoarthritis Outcome Score (KOOS) outcomes at 2 years and any incidence of knee complications that required surgery.

RESULTS

Two hundred-nine knees (35.2%) had a POD knee implanted, and 385 knees had an industry knee implanted. Both POD knees and industry knees showed statistically significant improvements (P < 0.0001) for all subgroups of the KOOS. No statistically significant difference was observed in improvement in any subgroup of the KOOS between the groups. Knee complications requiring surgical intervention were similar (2.9% POD knees versus 3.6% industry knees; P = 0.58). Using lower cost POD knees saved $209,875.71.

CONCLUSIONS

No difference was observed in improvements in outcomes or complications in the lower cost POD-supplied knees compared with the higher cost industry-supplied knees. Hospitals and surgeons may consider using lower cost prostheses because the increased cost of the prosthesis has not been correlated to improved outcomes.

LEVEL OF EVIDENCE

Level II therapeutic prospective cohort study.

Preoperative body mass index and physical function are associated with length of stay and facility discharge after total knee arthroplasty

BACKGROUND

Hospital length of stay (LOS) and facility discharge are primary drivers of the cost of total knee arthroplasty (TKA). We sought to identify modifiable patient factors that were associated with increased LOS and facility discharge after TKA.

METHODS

Prospective data were reviewed from 716 consecutive, primary TKA procedures performed by two arthroplasty surgeons between 2006 and 2012 at a single institution. Preoperative body mass index (BMI), Veterans RAND-12 (VR-12) physical component score (PCS), and hemoglobin level were collected in addition to other adjusters. Multivariate linear and logistic models were constructed to predict LOS and facility discharge, respectively.

RESULTS

After adjustment, higher BMI was associated with increased LOS in a dose-response effect: Compared to normal weight (BMI <25) overweight (25-29.9) was associated with longer LOS by 0.32days (P=0.038), class-I obesity (30-34.9) by 0.33days (P=0.024), class-II obesity (35-39.9) by 0.67days (P=0.012) and class-III obesity (>40) by 1.15days (P<0.001). Class-III obesity was associated with facility discharge (odds ratio=2.08, P=0.008). Poor PCS was associated with increasing LOS: compared to PCS≥50, PCS 20-29 was associated with a LOS increase of 0.40days (P=0.014) and PCS<20 with a LOS increase of 0.64days (P=0.031).

CONCLUSION

Patient BMI has a dose-response effect in increasing LOS. Poor PCS was associated similarly with increased LOS. These associations for of BMI and PCS suggest that improvement preoperatively, by any amount, may potentially translate to decreased LOS and perhaps lower the cost associated with TKA.

Impact of Race/Ethnicity and Socioeconomic Status on Risk-Adjusted Hospital Readmission Rates Following Hip and Knee Arthroplasty

BACKGROUND

Readmission rates following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are increasingly used to measure hospital performance. Readmission rates that are not adjusted for race/ethnicity and socioeconomic status, patient risk factors beyond a hospital's control, may not accurately reflect a hospital's performance. In this study, we examined the extent to which risk-adjusting for race/ethnicity and socioeconomic status affected hospital performance in terms of readmission rates following THA and TKA.

METHODS

We calculated 2 sets of risk-adjusted readmission rates by (1) using the Centers for Medicare & Medicaid Services standard risk-adjustment algorithm that incorporates patient age, sex, comorbidities, and hospital effects and (2) adding race/ethnicity and socioeconomic status to the model. Using data from the Healthcare Cost and Utilization Project, 2011 State Inpatient Databases, we compared the relative performances of 1,194 hospitals across the 2 methods.

RESULTS

Addition of race/ethnicity and socioeconomic status to the risk-adjustment algorithm resulted in (1) little or no change in the risk-adjusted readmission rates at nearly all hospitals; (2) no change in the designation of the readmission rate as better, worse, or not different from the population mean at >99% of the hospitals; and (3) no change in the excess readmission ratio at >97% of the hospitals.

CONCLUSIONS

Inclusion of race/ethnicity and socioeconomic status in the risk-adjustment algorithm led to a relative-performance change in readmission rates following THA and TKA at <3% of the hospitals. We believe that policymakers and payers should consider this result when deciding whether to include race/ethnicity and socioeconomic status in risk-adjusted THA and TKA readmission rates used for hospital accountability, payment, and public reporting.

LEVEL OF EVIDENCE

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

Novel chitosan/diclofenac coatings on medical grade stainless steel for hip replacement applications

Corrosion resistance, biocompatibility, improved osteointegration, as well the prevention of inflammation and pain are the most desired characteristics of hip replacement implants. In this study we introduce a novel multi-layered coating on AISI 316LVM stainless steel that shows promise with regard to all mentioned characteristics. The coating is prepared from alternating layers of the biocompatible polysaccharide chitosan and the non-steroid anti-inflammatory drug (NSAID), diclofenac. Electrochemical methods were employed to characterize the corrosion behavior of coated and uncoated samples in physiological solution. It is shown that these coatings improve corrosion resistance. It was also found that these coatings release the incorporated drug in controlled, multi-mechanism manner. Adding additional layers on top of the as-prepared samples, has potential for further tailoring of the release profile and increasing the drug dose. Biocompatibility was proven on human-derived osteoblasts in several experiments. Only viable cells were found on the sample surface after incubation of the samples with the same cell line. This novel coating could prove important for prolongation of the application potential of steel-based hip replacements, which are these days often replaced by more expensive ceramic or other metal alloys.

Does Surgical Approach Affect Patient-reported Function After Primary THA?

BACKGROUND

Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach.

QUESTIONS/PURPOSES

We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA?

METHODS

Between October 2008 and February 2010, an arthroplasty fellowship-trained surgeon performed 135 THAs. All 135 were performed using the posterior approach. During that period, we used this approach when patients had any moderate to severe degenerative joint disease of the hip attributable to any type of arthritis refractory to nonoperative treatment measures. Of the patients who were treated with this approach, 21 (17%; 23 hips) were lost to followup, whereas 109 (83%; 112 hips) were available for followup at 1 year. Between February and September 2011, the same surgeon performed 86 THAs. All 86 were performed using the direct-anterior approach. During that period, we used this approach when patients with all types of moderate to severe degenerative joint disease had nonoperative treatment measures fail. Of the patients who were treated with this approach, 35 (41%; 35 hips) were lost to followup, whereas 51 (59%; 51 hips) were available for followup at 1 year. THAs during the surgeon's direct-anterior approach learning period (February 2010 through January 2011) were excluded because both approaches were being used selectively depending on patient characteristics. Clinical outcomes included operative blood loss; allogeneic transfusion; adverse events; patient-reported Veterans RAND-12 Physical (PCS) and Mental Component Summary (MCS) scores, and University of California Los Angeles (UCLA) activity scores at 1 month, 3 months, and 1 year after surgery. Resource utilization outcomes included operative time, length of stay, and discharge disposition (home versus institution). Outcomes were compared using logistic and linear regression techniques.

RESULTS

After controlling for relevant confounding variables including age, sex, and BMI, the direct-anterior approach was associated with worse adjusted MCS changes 1 and 3 months after surgery (1-month score change, -9; 95% CI, -13 to -5; standard error, 2), compared with the posterior approach (3-month score change, -9; 95% CI, -14 to -3; standard error, 3) (both p < 0.001), while the direct-anterior approach was associated with greater PCS improvement at 3 months compared with the posterior approach (score change, 6; 95% CI, 2-10; standard error, 2; p = 0.008). There were no differences in adjusted PCS at either 1 month or 12 months, and no clinically important differences in UCLA scores. Although the PCS score differences are greater than the minimum clinically important difference of 5 points for this endpoint, the clinical importance of such a small effect is questionable. At 1 year after THA, there were no intergroup differences in self-reported physical function, although both groups had significant loss-to-followup at that time. Operative time (skin incision to skin closure) between the two groups did not differ (81 versus 79 minutes; p = 0.411). Mean surgical blood loss (403 versus 293 mL; p < 0.001; adjusted, 119 more mL; 95% CI, 79-160; p < 0.001) and in-hospital transfusion rates (direct-anterior approach, 20% [17/86] versus posterior approach, 10% [14/135], p = 0.050; adjusted odds ratio, 3.6; 95% CI, 1.3-10.1; p = 0.016) were higher in the direct-anterior approach group. With the numbers available, there was no difference in the frequency of adverse events between groups when comparing intraoperative complications, perioperative Technical Expert Panel complications, and other non-Technical Expert Panel complications within 1 year of surgery, although this study was not adequately powered to detect differences in rare adverse events.

CONCLUSIONS

With suitable experience, the direct-anterior approach can be performed with expected results similar to those of the posterior approach. There may be transient and small benefits to the direct-anterior approach, including improved physical function at 3 months after surgery. However, the greater operative blood loss and greater likelihood of blood transfusions, even when the surgeon is experienced, may be a disadvantage. Given some of the kinds of bias present that we found, including loss to followup, the conclusions we present should be considered preliminary, but it appears that any benefits that accrue to the patients who had the direct-anterior approach would be transient and modest. Prospective randomized studies on the topic are needed to address the differences between surgical approaches more definitively.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Who Should Not Undergo Short Stay Hip and Knee Arthroplasty? Risk Factors Associated With Major Medical Complications Following Primary Total Joint Arthroplasty

We retrospectively reviewed 1012 consecutive patients undergoing elective primary hip and knee arthroplasties to identify risk factors associated with postoperative complications. A total of 70 complications (6.9%) requiring additional physician interventions occurred following surgery and 59 (84%) occurred past 24 hours postoperatively. Independent multivariate risk factors for developing late (>24 hours) complications included COPD (adjusted OR 4.16), CHF (adjusted OR 9.71), CAD (adjusted OR 2.80), and cirrhosis (adjusted OR 8.43). These results suggest that most major medical complications requiring additional physician interventions occur greater than 24 hours following primary THA/TKA. Patients with history of COPD, CHF, CAD, and cirrhosis should not undergo short stay or outpatient TJA.

Clinical improvement and satisfaction after total joint replacement: a prospective 12-month evaluation on the patients' perspective

PURPOSE

To determine short-term improvements, satisfaction rates and the patient acceptable symptom state (PASS) after total joint replacement (TJR) for different patient-reported outcome measures (PROMs).

METHODS

This prospective cohort study included 426 consecutive patients undergoing total hip (n = 193) or knee arthroplasty (n = 233). The following PROMs were completed before TJR, and at 3, 6 and 12 months after surgery, respectively: WOMAC, Oxford Hip or Knee Score, Lower Extremity Functional Scale, University of California at Los Angeles (UCLA) activity scale and EuroQol-5 dimension (EQ-5D). Satisfaction rates and the PASS thresholds were also assessed.

RESULTS

THA patients improved quicker and achieved higher outcome scores than TKA patients. Comorbidities according to the Sangha score were moderately correlated with all PROM values in an inverse direction at all time points (r = -0.27 to -0.47, p < 0.01) in both groups. Satisfaction with the result of surgery improved over time. At 12 months, more than 90 % of the patients were satisfied or very satisfied with the achieved result. The THA group showed a higher proportion of very satisfied patients than the TKA group at all time points. PASS thresholds increased over time for all PROMs except for the UCLA and the EQ-5D in TKA patients.

CONCLUSIONS

More than 90 % of the patients will be satisfied 1 year after TJR. THA patients recover faster than TKA patients, i.e., they achieve higher PROM values at earlier follow-up time points. Cutoff values defining a successful result in terms of the PASS could be defined for all PROMs at different time points and can serve as reference for future studies and patient-oriented follow-ups.

Total joint Perioperative Surgical Home: an observational financial review

Background

The numbers of people requiring total arthroplasty is expected to increase substantially over the next two decades. However, increasing costs and new payment models in the USA have created a sustainability gap. Ad hoc interventions have reported marginal cost reduction, but it has become clear that sustainability lies only in complete restructuring of care delivery. The Perioperative Surgical Home (PSH) model, a patient-centered and physician-led multidisciplinary system of coordinated care, was implemented at UC Irvine Health in 2012 for patients undergoing primary elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). This observational study examines the costs associated with this initiative.

Methods

The direct cost of materials and services (excluding professional fees and implants) for a random index sample following the Total Joint-PSH pathway was used to calculate per diem cost. Cost of orthopedic implants was calculated based on audit-verified direct cost data. Operating room and post-anesthesia care unit time-based costs were calculated for each case and analyzed for variation. Benchmark cost data were obtained from literature search. Data are presented as mean ± SD (coefficient of variation) where possible.

Results

Total per diem cost was $10,042 ± 1,305 (13%) for TKA and $9,952 ± 1,294 (13%) for THA. Literature-reported benchmark per diem cost was $17,588 for TKA and $16,267 for THA. Implant cost was $7,482 ± 4,050 (54%) for TKA and $9869 ± 1,549 (16%) for THA. Total hospital cost was $17,894 ± 4,270 (24%) for TKA and $20,281 ± 2,057 (10%) for THA. In-room to incision time cost was $1,263 ± 100 (8%) for TKA and $1,341 ± 145 (11%) for THA. Surgery time cost was $1,558 ± 290 (19%) for TKA and $1,930 ± 374 (19%) for THA. Post-anesthesia care unit time cost was $507 ± 187 (36%) for TKA and $557 ± 302 (54%) for THA.

Conclusions

Direct hospital costs were driven substantially below USA benchmark levels using the Total Joint-PSH pathway. The incremental benefit of each step in the coordinated care pathway is manifested as a lower average length of stay. We identified excessive variation in the cost of implants and post-anesthesia care.

A cost-analysis model for anticoagulant treatment in the hospital setting

BACKGROUND

Rivaroxaban is the first oral factor Xa inhibitor approved in the US to reduce the risk of stroke and blood clots among people with non-valvular atrial fibrillation, treat deep vein thrombosis (DVT), treat pulmonary embolism (PE), reduce the risk of recurrence of DVT and PE, and prevent DVT and PE after knee or hip replacement surgery. The objective of this study was to evaluate the costs from a hospital perspective of treating patients with rivaroxaban vs other anticoagulant agents across these five populations.

METHODS

An economic model was developed using treatment regimens from the ROCKET-AF, EINSTEIN-DVT and PE, and RECORD1-3 randomized clinical trials. The distribution of hospital admissions used in the model across the different populations was derived from the 2010 Healthcare Cost and Utilization Project database. The model compared total costs of anticoagulant treatment, monitoring, inpatient stay, and administration for patients receiving rivaroxaban vs other anticoagulant agents. The length of inpatient stay (LOS) was determined from the literature.

RESULTS

Across all populations, rivaroxaban was associated with an overall mean cost savings of $1520 per patient. The largest cost savings associated with rivaroxaban was observed in patients with DVT or PE ($6205 and $2742 per patient, respectively). The main driver of the cost savings resulted from the reduction in LOS associated with rivaroxaban, contributing to ∼90% of the total savings. Furthermore, the overall mean anticoagulant treatment cost was lower for rivaroxaban vs the reference groups.

LIMITATIONS

The distribution of patients across indications used in the model may not be generalizable to all hospitals, where practice patterns may vary, and average LOS cost may not reflect the actual reimbursements that hospitals received.

CONCLUSION

From a hospital perspective, the use of rivaroxaban may be associated with cost savings when compared to other anticoagulant treatments due to lower drug cost and shorter LOS associated with rivaroxaban.