Over Half of All Medicare Total Knee Arthroplasty Patients Are Now Classified as an Outpatient–Three-Year Impact of the Removal From the Inpatient-Only List

BackgroundIn 2018, Centers for Medicare & Medicaid Services removed total knee arthroplasty (TKA) from its inpatient-only list, triggering many unintended consequences. The purpose of this study was to determine how the impact of TKA removal affected the number of outpatient TKA patients, which patients were being labeled outpatient, and how outpatient classification affected discharge location and readmission rates.MethodsUsing a large administrative claims database, we reviewed a consecutive series of 216,365 primary TKA Medicare patients from 2015 to 2020. Patients who had an inpatient status (n = 63,356) were compared to patients who had an outpatient status (n = 38,510) from 2018 to 2020 based on demographics, comorbidities, discharge dispositions, and readmissions.ResultsIn 2015, only 1.8% of TKA patients were designated as outpatients, but by 2020, 57.2% of Medicare TKA patients were classified as outpatients. A majority of patients (72%) who had an outpatient designation remained in the hospital for >24 hours (average length of stay was 2.7 days). Patients who had an outpatient status were discharged to skilled nursing facilities more frequently than patients who had an inpatient status (3.1 versus 2.0%, P < .001) with increased emergency visits (5.1 versus 3.9%, P < .001) and 90-day readmissions (2.2 versus 0.9%, P < .001).ConclusionOver half of all Medicare TKA patients are being classified as outpatients 3 years following the policy to remove TKA from the inpatient-only list. Patients designated as outpatients had higher readmissions than those designated as inpatients. This policy should be re-evaluated in the context of failure to demonstrate safer discharge of Medicare patients who undergo TKA.     

Is the New Outpatient Prospective Payment System Classification for Outpatient Total Knee Arthroplasty Appropriate?

BackgroundIn 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the inpatient-only list, resulting in payment through the Outpatient Prospective Payment System with an average $3157 reduction. The purpose of this study is to determine if the reimbursement is justified by comparing the difference in facility costs between inpatient and outpatient TKAs.MethodsWe identified 4496 consecutive primary TKA procedures performed at 2 hospitals from 2015 to 2019. Itemized facility costs were calculated using a time-driven activity-based costing algorithm. Outpatient procedures were defined as those with a length of stay of less than 2 midnights (3851, 86%). Patient demographics, comorbidities, and itemized costs were compared between groups. A multivariate regression analysis was performed to determine the independent effect of outpatient status on true facility costs.ResultsOutpatient TKA patients had lower mean postoperative personnel costs ($1809 vs $947, P < .001), supply costs ($4347 vs $4229, P < .001), and overall total facility costs ($7371 vs $6937, P < .001) than inpatient TKA patients. Controlling for a younger patient cohort with fewer medical comorbidities, outpatient status was associated with a reduction in total facility costs of $972 (95% confidence interval $883-$1060, P < .001) compared to inpatient TKA.ConclusionOutpatient TKA costs hospitals nearly $1000 per patient less than inpatient TKA, yet the average difference in Medicare reimbursement for an outpatient procedure is $3157 less per patient. Centers for Medicare and Medicaid Services should reconsider the Outpatient Prospective Payment System classification of TKA to better incentivize surgeons to perform TKA as a lower cost outpatient procedure when safe and appropriate.     

Trends in Revenue,Cost, and Contribution Margin for Total Joint Arthroplasty 2011-2021

BackgroundRegulatory change has created a growing demand to decrease the hospital costs associated with primary total joint arthroplasty (TJA). Concurrently, the removal of lower extremity TJA from the in-patient only list has affected hospital reimbursement. The purpose of this study is to investigate trends in hospital revenue versus costs in primary TJA.MethodsWe retrospectively reviewed all patients who underwent primary TJA from June 2011 to May 2021 at our institution. Patient demographics, revenue, total cost, direct cost, and contribution margin were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analysis was used to determine overall trend significance and develop projection models.ResultsTotal knee arthroplasty (TKA) insured by government-managed/Medicaid (GMM) plans showed a significant upward trend (P = .013) in total costs. Direct costs of TKA across all insurance providers (P = .001 and P < .001) and total hip arthroplasty (THA) for Medicare (P = .009) and GMM (P = .001) plans demonstrated significant upward trends. Despite this, 2011-2021 modeling found no significant change in contribution margin for TKA and THA covered under all insurance plans. However, models based on 2018-2021 financial data demonstrated a significant downward trend in contribution margin across Medicare (P < .001) and GMM (P < .001) insurers for both TKA and THA.ConclusionPhysician-led innovation in cost-saving strategies has maintained contribution margin over the past decade. However, the increase in direct costs seen over the past few years could lead to negative contribution margins over time, if further efficiency and cost-saving measures are not developed.Level III EvidenceRetrospective Cohort Study.     

Formal Physical Therapy Following Total Hip and Knee Arthroplasty Incurs Additional Cost Without Improving Outcomes

BackgroundRecent evidence has demonstrated that formal physical therapy (PT) may not be required for most patients undergoing total hip (THA) and knee (TKA) arthroplasty. This study compared the differences in costs and functional outcomes in patients receiving formal PT and those who did not follow primary THA and TKA.MethodsWe queried claims data from a single private insurer identifying patients who underwent primary THA or TKA from 2015 to 2017 in our practice. Demographics, comorbidities, number, and cost of PT visits in a 90-day episode of care were recorded. Outcomes were compared between patients using self-directed home exercises, home PT, outpatient PT, or both home and outpatient PT. A multivariate analysis was performed to identify significant predictors of outcomes.ResultsOf the 2971 patients included in analysis, patients using both services had higher 90-day PT costs (mean $2091, P < .001) than those using home PT alone ($1146), outpatient PT alone ($1356), or no formal PT ($0). Home PT had the greatest cost per visit for both private insurance patients ($177/visit) and Medicare Advantage patients ($157/visit), but patients using both home PT and outpatient PT services had the greatest overall PT cost, $2091 for private insurance and $1891 for Medicare Advantage. Patients who used home PT were at significantly higher risk of both complications (odds ratio = 3.21; 95% confidence interval, 2.1-4.9; P < .001) and readmissions (odds ratio = 3.4; 95% confidence interval, 2.1-5.5; P < .001).ConclusionParticipation in formal PT accounts for up to 8% of the episode of care following THA and TKA. The role of formal PT for most patients should take into account the cost-effectiveness of the intervention.     

Amount of CMS Reduction in Facility Reimbursement Following Removal of Total Hip Arthroplasty From the Inpatient-Only List Far Exceeds Reduction in Actual Care Cost

BackgroundStarting in 2020, Centers for Medicare and Medicaid Services (CMS) removed total hip arthroplasty (THA) from the inpatient-only list, resulting in an average of $1637 per case reduction in facility reimbursement. The purpose of this study is to determine whether the reduction in reimbursement is justified by comparing the difference in true facility costs between inpatient and outpatient THA.MethodsWe identified a consecutive series of 5271 primary THA procedures from 2015 to 2019. Itemized procedural costs were calculated using a time-driven activity-based costing algorithm. Outpatient procedures were defined as those with less than a 24-hour length of stay. We compared patient demographics, comorbidities, and itemized costs between inpatient and outpatient procedures. A multivariate analysis was performed to determine the independent effect of outpatient status on true facility costs.ResultsThere were 783 (14.9%) outpatient THA procedures. The outpatient THA procedures incurred lower mean personnel ($1428 vs $2226, P < .001), supply ($4713 vs $4739, P < .001), and overall facility costs ($6141 vs $6595, P < .001) when compared with the same THA procedures done inpatient. When controlling for confounding variables, outpatient status was associated with a reduction in total facility costs of $825 (95% confidence interval, $734-$916, P < .001).ConclusionThe reduction in CMS reimbursement far exceeds the $825 per-patient cost savings that can be achieved by a facility by performing THA as an outpatient. CMS should reconsider the Outpatient Prospective Payment System classification of THA to better incentivize surgeons to perform THA as a lower-cost outpatient procedure when safe and appropriate.     

The Impact of Mental Illness on Postoperative Adverse Outcomes After Outpatient Joint Surgery

BackgroundThe effect of pre-existing mental illness on outpatient surgical outcomes is not well characterized. The objective of this study was to evaluate the association between pre-existing mental illness diagnosis and postoperative complications after outpatient total knee (TKA) and total hip arthroplasty (THA) and 2) compare with inpatient total joint arthroplasty (TJA).MethodsThe Mariner Claims Database was used to capture patients undergoing outpatient TJA from 2010 to 2017. Patients were grouped into three categories: those with an existing history of anxiety and/or depression, those with severe mental illness, and those without history of mental illness. Additional subgroup analysis compared those with severe mental illness undergoing outpatient vs inpatient TJA. Outcomes were analyzed using multivariable logistic regression (P < .05).ResultsPatients undergoing outpatient TJA with prior history of anxiety and/or depression or severe mental illness had an increased risk of emergency department (ED) visits (TKA, P < .001; THA, P = .014) within 90 days compared with those without history of mental illness. Severe mental illness was also associated with increased risk of medical complications at 90 days (TKA, P < .001; THA, P = .006). When compared with those undergoing inpatient surgery, patients undergoing outpatient TKA with severe mental illness were at increased risk of periprosthetic infection (P = .005) and ED visit (P = .003) within 90 days of surgery.ConclusionAnxiety/depression and severe mental illness are associated with higher rates of ED visits after outpatient TJA. Patients with severe mental illness also experienced more adverse events, whereas those with anxiety and/or depression had similar rates compared with control. A higher rate of adverse outcomes was seen after TKA in patients with severe mental illness when surgery was performed in the outpatient setting vs those that had surgery as an inpatient.Level of EvidenceIII.     

Major National Shifts to Outpatient Total Knee Arthroplasties in the United States: A 10-Year Trends Analysis of Procedure Volumes,Complications, and Healthcare Utilizations (2010 to 2020)

BackgroundThe removal of total knee arthroplasty (TKA) from inpatient-only lists accelerated changes in orthopaedic surgical practices across the United States. This study aimed to (1) quantify the annual volume of inpatient/outpatient primary TKAs; (2) compare patient characteristics before/after the year 2018; and (3) compare annual trends in 30-day readmissions, 30-day complications, and healthcare utilization parameters for inpatient/outpatient TKAs.MethodsThe National Surgical Quality Improvement Program was reviewed (January 2010 to December 2020) for patients who underwent primary TKA (n = 470,456). The primary outcome was annual volumes of inpatient/outpatient TKA. Secondary outcomes included 30-day readmissions, 30-day reoperations, and 30-day major/minor complications. Demographic characteristics and healthcare utilization parameters (hospital lengths of stay and discharge dispositions) were compared between cohorts via Chi-square goodness-of-fit tests.ResultsOverall, 89% had inpatient TKA (n = 416,972) and 11% had outpatient TKA (n = 53,854). Between 2017 and 2020, annual volumes of outpatient TKA increased by 1,925 (1,019 to 20,633), while inpatient TKA decreased by 53% (61,874 to 29,280). Patients who had outpatient TKA after 2018 were older (P < .001), predominantly males (P < .001), more commonly White (P < .001), and had a greater proportion of American Society of Anesthesiologists class III (P < .001). The inpatient cohort had higher rates of 30-day readmissions, reoperations, and complications. Average length of stay and nonhome discharges decreased for both cohorts.ConclusionOutpatient TKA increased 20-fold at NSQIP hospitals. The changes in comorbidity profiles and the increase in volumes of outpatient TKA were not associated with a rise in cumulative 30-day readmissions and complications. Further research and policy endeavors should focus on identifying patients who still require or benefit from inpatient TKA.     

Surgeon Reimbursement Unchanged as Hospital Charges and Reimbursements Increase for Total Joint Arthroplasty

BackgroundDespite increasing demands on physicians and hospitals to increase value and reduce unnecessary costs, reimbursement for healthcare services has been under downward pressure for several years. This study aimed to analyze the trend in hospital charges and payments relative to corresponding surgeon charges and payments in a Medicare population for total hip (THA) and knee arthroplasty (TKA).MethodsThe 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 56,228 patients who underwent primary THA and 117,698 patients who underwent primary TKA between 2005 and 2014. Two values were calculated: (1) the charge multiplier (CM), the ratio of hospital to surgeon charges and (2) the payment multiplier (PM), the ratio of hospital to surgeon payments. Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated.ResultsHospital charges were significantly higher than surgeon charges and increased substantially for both THA (CM increased from 8.7 to 11.5, P < .0001) and TKA (CM increased from 7.9 to 11.4, P < .0001). PM followed a similar trend, increasing for both THA and TKA (P < .0001). LOS decreased significantly for both THA and TKA (P < .0001), while Charlson Comorbidity Index remained stable. Both CM (r² = 0.84 THA, 0.90 TKA) and PM (r² = 0.75 THA, 0.84 TKA) were strongly negatively associated with LOS.ConclusionHospital charges and payments relative to surgeon charges and payments have increased substantially for THA and TKA despite stable patient complexity and decreasing LOS.     

The Effect of Neuraxial Anesthesia on Postoperative Outcomes in Total Joint Arthroplasty With Rapid Recovery Protocols

BackgroundCompared to general anesthesia (GA), neuraxial anesthesia (NA) has been associated with improved outcomes after total joint arthroplasty (TJA). We examined the impact of NA on patient outcomes in an institution with an established rapid recovery protocol.MethodsThis is a single-institution retrospective analysis of 5914 consecutive primary TJA performed from July 2015 to June 2018. Univariate tests and multivariate regression compared length of stay (LOS), transfusion rates, hematocrit levels, discharge disposition, and emergency room returns between patients receiving GA and NA.ResultsPatients receiving NA had a significantly shorter LOS (total hip arthroplasty [THA]: GA 1.74 vs NA 1.36 days, P < .001; total knee arthroplasty [TKA]: GA 1.77 vs NA 1.64 days, P < .001). Both THA and TKA patients receiving NA were less likely to require transfusion (THA: GA 5.8% vs NA 1.6%, P < .001; TKA: GA 2.5% vs NA 0.5%, P < .001) and had a higher postoperative hematocrit (THA: GA 32.50% vs NA 33.22%, P < .001; TKA GA 33.57 vs NA 34.50%, P < .001). Patients receiving NA were more likely to discharge home (THA: GA 83.4% vs NA 92.3%, P < .001; TKA: GA 83.3% vs NA 86.3%, P = .010) (THA: NA adjusted OR [aOR] 2.04, P < .001; TKA: NA aOR 1.23, P = .048) and had significantly lower rates of 90-day emergency room visits (THA: NA aOR 0.61, P = .005; TKA: NA aOR 0.74, P = .034).ConclusionNA appears to contribute to decreased LOS, short-term complications, and transfusions while facilitating home discharge following TKA and THA. These trends are consistent when controlling for patient-specific risk factors, suggesting NA may enhance outcomes for patients with increased age, body mass index, and comorbidities.Level Of EvidenceLevel III Retrospective Cohort Study.     

Same-Day Discharge Total Hip and Knee Arthroplasty: Trends,Complications, and Readmission Rates

BackgroundAlthough total hip arthroplasty (THA) and total knee arthroplasty (TKA) are transitioning to surgery centers, there remain limited data on trends, comorbidities, and complications in patients discharged the same day of surgery. In addition, many studies are limited to the Medicare population, excluding a large proportion of outpatient surgery patients.MethodsPrimary, elective THA/TKA cases between 2010 and 2017 were retrospectively identified using the PearlDiver All-Payer Database and separated based on surgery as well as same-day discharge (SDD) or non-SDD. Data were collected on demographics, rates, comorbidities, and complications. Multivariable logistic regression determined adjusted odds ratios (ORs) for 90-day complications requiring readmission for each group.ResultsIn total, 1,789,601 (68.8% TKA, 31.2% THA) patients were identified where 2.9% of TKAs and 2.2% of THAs were SDD. Annual SDD rates are increasing, with a 15.8% mean annual change for SDD-THA and 11.1% for SDD-TKA (P < .001). SDD patients were younger with fewer comorbidities (P < .001). Regression analysis showed an overall slightly higher OR of complications requiring readmission for SDD-TKA vs non-SDD-TKA (OR 1.14, 95% confidence interval [CI] 1.07-1.21, P < .001). There was no significant difference for SDD-THA vs non-SDD-THA (OR 1.03, 95% CI 0.94-1.13, P = .49). In univariate analysis, SDD-THA vs SDD-TKA had more mechanical complications (P < .001), but less pulmonary embolisms (P < .001). Regression analysis showed a slightly higher risk of complications for SDD-THA vs SDD-TKA (OR 1.19, 95% CI 0.99-1.44, P = .05).ConclusionThe prevalence of SDD is rising. SDD-THA is increasing more rapidly than SDD-TKA. SDD patients are generally younger with fewer comorbidities. SDD-TKA has slightly higher odds of complications requiring readmission than non-SDD-TKA. SDD-THA and SDD-TKA have different complication profiles.     

From Winners to Losers: The Methodology of Bundled Payments for Care Improvement Advanced Disincentivizes Participation in Bundled Payment Programs

BackgroundThe Bundled Payments for Care Improvement (BPCI) initiative improved quality and reduced costs following total hip (THA) and knee arthroplasty (TKA). In October 2018, the BPCI-Advanced program was implemented. The purpose of this study is to compare the quality metrics and performance between our institution’s participation in the BPCI program with the BPCI-Advanced initiative.MethodsWe reviewed a consecutive series of Medicare primary THA and TKA patients. Demographics, medical comorbidities, discharge disposition, readmission, and complication rates were compared between BPCI and BPCI-Advanced groups. Medicare claims data were used to compare episode-of-care costs, target price, and margin per patient between the cohorts.ResultsCompared to BPCI patients (n = 9222), BPCI-Advanced patients (n = 2430) had lower rates of readmission (5.8% vs 3.8%, P = .001) and higher rate of discharge to home (72% vs 78%, P < .001) with similar rates of complications (4% vs 4%, P = .216). Medical comorbidities were similar between groups. BPCI-Advanced patients had higher episode-of-care costs ($22,044 vs $18,440, P < .001) and a higher mean target price ($21,154 vs $20,277, P < .001). BPCI-Advanced patients had a reduced per-patient margin compared to BPCI ($890 loss vs $1459 gain, P < .001), resulting in a $2,138,670 loss in the first three-quarters of program participation.ConclusionDespite marked improvements in quality metrics, our institution suffered a substantial loss through BPCI-Advanced secondary to methodological changes within the program, such as the exclusion of outpatient TKAs, facility-specific target pricing, and the elimination of different risk tracks for institutions. Medicare should consider adjustments to this program to keep surgeons participating in alternative payment models.     

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

BackgroundConcerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution’s exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A).MethodsWe reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions.Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions.ResultsPost-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224).ConclusionsSince leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.     

Risk of Prosthetic Joint Infection Increases Following Early Aseptic Revision Surgery of Total Hip and Knee Arthroplasty

BackgroundIt is important to identify risk factors for periprosthetic joint infection (PJI) following total joint arthroplasty in order to mitigate the substantial social and economic burden. The objective of this study is to evaluate early aseptic revision surgery as a potential risk factor for PJI following total hip (THA) and total knee arthroplasty (TKA).MethodsPatients who underwent primary THA or TKA with early aseptic revision were identified in 2 national insurance databases. Control groups of patients who did not undergo revision were identified and matched 10:1 to study patients. Rates of PJI at 1 and 2 years postoperatively following revision surgery were calculated and compared to controls using a logistic regression analysis.ResultsIn total, 328 Medicare and 222 Humana patients undergoing aseptic revision THA within 1 year of index THA were found to have significantly increased risk of PJI at 1 year (5.49% vs 0.91%, odds ratio [OR] 5.61, P < .001 for Medicare; 7.21% vs 0.68%, OR 11.34, P < .001 for Humana) and 2 years (5.79% vs 1.10%, OR 4.79, P < .001 for Medicare; 8.11% vs 1.04%, OR 9.05, P < .001 for Humana). Similarly for TKA, 190 Medicare and 226 Humana patients who underwent aseptic revision TKA within 1 year were found to have significantly higher rates of PJI at 1 year (6.48% vs 1.16%, OR 7.69, P < .001 for Medicare; 6.19% vs 1.28%, OR 4.89, P < .001 for Humana) and 2 years (8.42% vs 1.58%, OR 6.57, P < .001 for Medicare; 7.08% vs 1.50%, OR 4.50, P < .001 for Humana).ConclusionEarly aseptic revision surgery following THA and TKA is associated with significantly increased risks of subsequent PJI within 2 years.     

Preoperative Predictors of Patients Requiring Inpatient Admission for Total Hip Arthroplasty Following Removal From the Medicare Inpatient-Only List

BackgroundThe Centers for Medicare and Medicaid Services has removed total hip arthroplasty from the inpatient-only (IO) list in January 2020. Given the confusion created when total knee arthroplasty came off the IO list in 2018, this study aims to develop a predictive model for guiding preoperative inpatient admission decisions based upon readily available patient demographic and comorbidity data.MethodsThis is a retrospective review of 1415 patients undergoing elective unilateral primary THA between January 2018 and October 2019. Multiple logistic regression was used to develop a model for predicting LOS ≥2 days based on preoperative demographics and comorbidities.ResultsControlling for other demographics and comorbidities, increased age (odds ratio [OR], 1.048; P < .001), female gender (OR, 2.284; P < .001), chronic obstructive pulmonary disorder (OR, 2.249; P = .003), congestive heart failure (OR, 8.231; P < .001), and number of comorbidities (OR, 1.216; P < .001) were associated with LOS ≥2 days while patients with increased body mass index (OR, 0.964; P = .007) and primary hypertension (OR, 0.671; P = .008) demonstrated significantly reduced odds of staying in the hospital for 2 or more days. The area under the curve was found to be 0.731, indicating acceptable discriminatory value.ConclusionFor patients undergoing primary THA, increased age, female gender, chronic obstructive pulmonary disorder, congestive heart failure, and multiple comorbidities are risk factors for inpatient hospital LOS of 2 or more days. Our predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in preoperatively identifying patients requiring inpatient admission with removal of THA from the Medicare IO list.     

A Novel,Synergistic Model in Total Joint Arthroplasty: A Report of 2 Specialty Hospitals With Joint Ownership Between Physicians and Healthcare Systems

BackgroundIn 2010, the Affordable Care Act introduced new restrictions on the expansion of physician-owned hospitals (POHs) due to concerns over financial incentives and increased costs. The purpose of this study is to determine whether joint ventures between tertiary care and specialty hospitals (SHs) allowing physician ownership (POHs) have improved outcomes and lower cost following THA and TKA.MethodsAfter institutional review board approval, a retrospective review of consecutive series of primary THA and TKA patients from 2015 to 2016 across a single institution comprised of 14 full-service hospitals and 2 SHs owned as a joint venture between physicians and their health system partners. Ninety-day episode-of-care claims cost data from Medicare and a single private insurer were reviewed with the collection of the same demographic data, medical comorbidities, and readmission rates for both the SHs and non-SHs. A multivariate regression analysis was performed to determine the independent effect of the SHs on episode-of-care costs.ResultsOf the 6537 patients in the study, 1936 patients underwent a total joint arthroplasty at an SH (29.6%). Patients undergoing a procedure at an SH had shorter lengths of stay (1.29 days vs 2.23 days for Medicare, 1.15 vs 1.86 for private payer, both P < .001), were less likely to be readmitted (4% vs 7% for Medicare, P = .001), and had lower mean 90-day episode-of-care costs ($16,661 vs $20,579 for Medicare, $26,166 vs $35,222 for private payers, both P < .001). When controlling for the medical comorbidities and demographic variables, undergoing THA or TKA at an SH was associated with a decrease in overall episode costs ($3266 for Medicare, $13,132 for private payer, both P < .001).ConclusionEven after adjusting for a healthier patient population, the joint venture partnership with health systems and physician-owned SHs demonstrated lower 90-day episode-of-care costs than non-SHs following THA and TKA. Policymakers and practices should consider these data when considering the current care pathways.     

Frailty,Race/Ethnicity,Functional Status,and Adverse Outcomes After Total Hip/Knee Arthroplasty: A Moderation Analysis

BackgroundAlthough frailty has been shown to be associated with adverse outcomes in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), prior studies have not examined how race/ethnicity might moderate these associations. We aimed to assess race/ethnicity as a potential moderator of the associations of frailty and functional status with arthroplasty outcomes.MethodsThe National Surgical Quality Improvement Program was queried for patients who underwent THA or TKA from 2011 to 2017. Frailty was assessed using the modified frailty index. Regression analyses were conducted to examine associations connecting frailty/functional status with 30-day readmission, adverse discharge, and length of stay (LOS). Further analyses were conducted to investigate race/ethnicity as a potential moderator of these relationships.ResultsWe identified 219,143 TKA and 130,022 THA patients. Frailty and nonindependent functional status were positively associated with all outcomes (P < .001). Compared to White non-Hispanic patients, Black non-Hispanic patients had higher odds for all outcomes after TKA (P < .001) and for adverse discharge/longer LOS after THA (P < .001). Similar associations were observed for Hispanics for the adverse discharge/LOS outcomes. Race/ethnicity moderated the effects of frailty in TKA for all outcomes and in THA for adverse discharge/LOS. Race/ethnicity moderated the effects of nonindependent function in TKA for adverse discharge/LOS and on LOS alone for THA.ConclusionDisparities for Black non-Hispanic and Hispanic patients persist for readmission, adverse discharge, and LOS. However, the effects of increasing frailty and nonindependent functional status on these outcomes were the most pronounced among White non-Hispanic patients.     

Utilization of Debridement,Antibiotics, and Implant Retention for Infection After Total Joint Arthroplasty Over a Decade in the United States

BackgroundReported clinical outcomes have varied for debridement, antibiotics, and implant retention (DAIR) and little is known regarding trends in utilization. We sought to evaluate the rate of DAIR utilization for total knee arthroplasty (TKA) and total hip arthroplasty (THA) periprosthetic joint infection (PJI) over a decade and clinical factors associated with these trends.MethodsA retrospective study of primary TKAs and THAs was performed using Medicare data from 2005 to 2014 using the PearlDiver database platform. Current Procedural Technology and International Classification of Diseases Ninth Edition codes identified patients who underwent a surgical revision for PJI, whether revision was a DAIR, as well as associated clinical factors including timing from index arthroplasty.ResultsThe proportion of revision TKAs and THAs performed using DAIR was 27% and 12% across all years, respectively. This proportion varied by year for TKAs and THAs with a linear trend toward increasing relative use of DAIR estimated at 1.4% and 0.9% per year (P < .001; P < .001). DAIR for TKA and THA performed within 90 days increased at a faster rate, 3.4% and 2.1% per year (P < .001; P < .001). Trends over time in TKA DAIRs showed an association with Elixhauser Comorbidity Index (ECI), 0-5 group increasing at 2.0% per year (P = .03) and patients >85 years (P = .04).ConclusionThe proportion of revision arthroplasty cases for PJI managed with DAIR has been increasing over time in the United States, with the most substantial increase seen <90 days from index arthroplasty. Age, gender, and ECI had a minimal association with this trend, except in the TKA population >85 years and in those with a very low ECI score.     

How to Develop a Fair Revision Arthroplasty Bundle? Using Perioperative Complications and Readmissions to Investigate

BackgroundThe next frontier for value-based health care in total joint arthroplasty is revision surgery. Although the disparity in health care utilization between revision procedures compared with primary total hip and total knee arthroplasty (THA/TKA) procedures is recognized, no agreement regarding the risk adjustment necessary to make revision bundles fair to both payors and providers exists. The purpose of this study is to use the risk of perioperative complications and readmissions of patients undergoing revision THA/TKA to establish the foundations of a fair revision arthroplasty bundle.MethodsWe retrospectively evaluated a consecutive series of 484 aseptic THA/TKA revisions performed at our institution over a 12-month period and compared complications, length of stay, reoperations, and 90-day readmissions to a group of 802 consecutive patients undergoing primary THA/TKA.Results169 (34.9%) patients experienced major complications after revision THA/TKA compared with 176 (21.9%) patients undergoing primary THA/TKA (P < .001), (OR 1.91 CI 1.49-2.45, P < .001). Patients undergoing revision TKA were 3.64 times more likely to require hospitalization greater than 3 days (OR 2.59-5.12, CI 95%, P < .001), whereas patients undergoing revision THA were 4.46 times more likely to require hospitalization greater than 3 days (OR 2.89-6.87, CI 95%, P < .001). Revision patients were 3X more likely to have a 90-day readmission and 4X more likely to have a reoperation.ConclusionFor a revision bundle to be fair and widely adopted, either significant financial incentive must be instituted or the latitude given to exclude outliers from the final reconciliation. This must be adjusted to not disincentivize institutions from providing care for failed hip and knee arthroplasties.     

High Bundled Payment Costs Following Total Hip and Knee Arthroplasty in African Americans

BackgroundConcerns exist that minorities who utilize more resources in an episode-of-care following total hip (THA) and knee arthroplasty (TKA) may face difficulties with access to quality arthroplasty care in bundled payment programs. The purpose of this study is to determine if African American patients undergoing TKA or THA have higher episode-of-care costs compared to Caucasian patients.MethodsWe queried Medicare claims data for a consecutive series of 7310 primary TKA and THA patients at our institution from 2015 to 2018. We compared patient demographics, comorbidities, readmissions, and 90-day episode-of-care costs between African American and Caucasian patients. A multivariate regression analysis was performed to identify the independent effect of race on episode-of-care costs.ResultsCompared to Caucasians, African Americans were younger, but had higher rates of pulmonary disease and diabetes. African American patients had increased rates of discharge to a rehabilitation facility (20% vs 13%, P < .001), with higher subacute rehabilitation ($1909 vs $1284, P < .001), home health ($819 vs $698, P = .022), post-acute care ($5656 vs $4961, P = .008), and overall 90-day episode-of-care costs ($19,457 vs $18,694, P = .001). When controlling for confounding comorbidities, African American race was associated with higher episode-of-care costs of $440 (P < .001).ConclusionAfrican American patients have increased episode-of-care costs following THA and TKA when compared to Caucasian patients, mainly due to increased rates of home health and rehabilitation utilization. Further study is needed to identify social variables that can help reduce post-acute care resources and prevent reduction in access to arthroplasty care in bundled payment models.     

Satisfaction With the Process vs Outcome of Care in Total Hip and Knee Arthroplasty

BackgroundPatient satisfaction, with both process of care and outcome of care, is critical for measuring the quality and value of elective procedures such as arthroplasty. The purpose of this study is to evaluate the correlation between early postoperative satisfaction with the process of care and 2-year satisfaction with the outcome of care after total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsWe retrospectively analyzed data from institutional arthroplasty registries. Satisfaction with the outcome of care was measured on a scale of 0-100 by a previously validated questionnaire administered 2 years postoperatively. Patient satisfaction with the process of care was measured by the Press Ganey (PG) inpatient survey, also scored 0-100. We examined the correlation between these 2 measures of satisfaction in patients who underwent primary THA or TKA.ResultsIn total, 721 TKA patients and 760 THA patients underwent surgery and completed both the PG survey and 2-year satisfaction questionnaire. The mean age was 65.1 years with a mean body mass index of 28.8 and 56% were female. The mean PG survey score for the entire cohort was 95.6. The mean 2-year satisfaction score was 90.3. The Spearman correlation coefficient between the PG survey and the 2-year satisfaction survey was 0.23 for TKA patients (P < .001) and 0.13 for THA patients (P < .001).ConclusionWe found a weak correlation between the measurement of satisfaction with the process of care surrounding hip and knee arthroplasty using the PG survey and measurement of satisfaction with the outcome of care after arthroplasty using a validated 2-year satisfaction instrument.