Financial Distress and Discussing the Cost of Total Joint Arthroplasty

Background

Total joint arthroplasty is expensive. Out-of-pocket cost to patients undergoing elective total joint arthroplasty varies considerably depending on their insurance coverage but can range into the tens of thousands of dollars. The goal of this study is to evaluate the association between patient financial stress and interest in discussing costs associated with surgery.

Clinical Pharmacist Service Associated With Improved Outcomes and Cost Savings in Total Joint Arthroplasty

BackgroundInstitutions providing total joint arthroplasty (TJA) procedures are subject to substantial outcomes reporting, including those influencing payment for services. Although clinical pharmacists are well-poised to add value, a comprehensive approach to optimizing pharmacotherapy across the care continuum for TJA patients has not been described.MethodsThis prospective, interventional, sequential cohort study was approved by our Institutional Review Board. The objective was to assess the impact of an Orthopedic Clinical Pharmacist service on institutional TJA complication rates and costs. Outcomes were compared for a Baseline period of July 2015 to February 2016 and a Post-implementation period of September 2016 to February 2017, allowing for a 6-month run-in period. Additionally, we pursued a post-discharge, RN-administered patient survey and an exploratory economic assessment.ResultsA total of 1715 TJA procedures were performed at the institution during the 20-month study timeframe. Postoperative readmission rate (1.3% vs 4.8%, P = .002) and complication rate (1.8% vs 3.4%, P = .760) were lower in the Post-implementation period. Postoperative VTE rate decreased to zero in the Post-implementation period (0.0% vs 0.6%, P = .13) and average hospital length of stay was unchanged (2.8 vs 2.9 days). Patient self-rated understanding of discharge medications was improved and satisfaction with pharmacist interaction was very high. The service conferred an estimated $73,410 net annual cost savings to the institution.ConclusionIntegration of a clinical pharmacist service for TJA patients was associated with clinically meaningful improvements in institutional outcomes, likely conferring substantial cost-benefit.     

Total Joint Arthroplasty and Preoperative Low Back Pain

Lower extremity osteoarthritis with concomitant low-back pain (LBP) may obscure a clinician’s ability to properly evaluate the status of hip or knee osteoarthritis and subsequent total joint arthroplasty (TJA) candidacy. A prospective cohort study was conducted to determine prevalence and severity of preoperative LBP among TJA patients, and the effect of TJA on alleviating LBP. Preoperative moderate to worst imaginable LBP pain on the Oswestry Disability Index (ODI) was significantly higher among hips compared to knees (28.8% vs. 16.1%, P < 0.0001). Compared to knees, hips also saw significant ODI improvement from preoperative to one-year postoperative. TJA candidates with considerable preoperative LBP should be counselled that TJA outcome may be impaired by the coexistence of spine disease, and that residual spine pain may continue following otherwise successful TJA.     

Emerging Racial Disparities in Outpatient Utilization of Total Joint Arthroplasty

BackgroundRacial and ethnic disparities within the field of total joint arthroplasty (TJA) have been extensively reported. To date, however, it remains unknown how these disparities have translated to the outpatient TJA (OP-TJA) setting. The purposes of this study were to compare relative OP-TJA utilization rates between White and Black patients from 2011-2019 and assess how these differences in utilization have evolved over time.MethodsWe conducted a retrospective review from 2011-2019 using the National Surgical Quality Improvement Program (NSQIP). Differences in the relative utilization of OP (same-day discharge) versus inpatient TJA between White and Black patients were assessed and trended over time. Multivariable logistic regressions were run to adjust for baseline patient factors and comorbidities.ResultsDuring the study period, Black patients were significantly less likely to undergo OP-TJA when compared to White patients (P < .001 for both outpatient total knee arthroplasty and outpatient total hip arthroplasty [OP-THA]). From 2011 to 2019, an emerging disparity was found in outpatient total knee arthroplasty and OP-THA utilization between White and Black patients (eg, White versus Black OP-THA: 0.4% versus 0.6% in 2011 compared with 10.2% versus 5.9% in 2019, P_trend < .001). These results held in all adjusted analyses.ConclusionIn this study we found evidence of emerging and worsening racial disparities in the relative utilization of OP-TJA procedures between White and Black patients. These results highlight the need for early intervention by orthopaedic surgeons and policy makers alike to address these emerging inequalities in access to care before they become entrenched within our systems of orthopaedic care.     

An Overview of Telehealth in Total Joint Arthroplasty

With the increase in technological advances over the years, telehealth services in orthopedic surgery have gained in popularity, yet adoption among surgeons has been slow. With the onset of the COVID-19 pandemic, however, orthopedic surgery practices nationwide have accelerated adaptation to telemedicine. Telehealth can be effectively applied to total joint arthroplasty, with the ability to perform preoperative consultations, postoperative follow-up, and telerehabilitation in a virtual, remote manner with similar outcomes to in-person visits. New technologies that have emerged, such as virtual goniometers, wearable sensors, and app-based patient questionnaires, have improved clinicians’ ability to conduct telehealth visits. Benefits of using telehealth include high patient satisfaction, cost-savings, increased access to care, and more efficiency. Notably, some challenges still exist, including widespread accessibility and adaptation of new technologies, inability to conduct an in-person orthopedic physical examination, and regulatory barriers, such as insurance reimbursement, increased medicolegal risk, and privacy and confidentiality concerns. Despite these hurdles, telehealth is here to stay and can be successfully incorporated in any total joint arthroplasty practice with the appropriate adjustments.     

Perioperative Statin Use May Reduce Postoperative Arrhythmia Rates After Total Joint Arthroplasty

BackgroundPostoperative arrhythmias are associated with increased morbidity and mortality in total joint arthroplasty (TJA) patients. HMG-CoA (3-hydroxy-3-methyl-glutaryl-CoA) reductase inhibitors (statins) decrease atrial fibrillation rates after cardiac surgery, but it is unknown if this cardioprotective effect is maintained after joint reconstruction surgery. We aim to determine if perioperative statin use decreases the incidence of 90-day postoperative arrhythmias in patients undergoing primary TJA.MethodsWe performed a single-center retrospective cohort study in which 231 primary TJA patients (109 hips, 122 knees) received simvastatin 80 mg daily during their hospitalization as part of a single surgeon’s standard postoperative protocol. This cohort was matched to 966 primary TJA patients (387 hips and 579 knees) that did not receive simvastatin. New-onset arrhythmias (bradycardia, atrial fibrillation/tachycardia/flutter, paroxysmal supraventricular tachycardia, and ventricular tachycardia) and complications (readmissions, thromboembolism, infection, and dislocation) within 90 days of the procedure were documented. Categorical variables were analyzed using Fisher’s exact tests. Our study was powered to detect a 3% difference in arrhythmia rates.ResultsWithin 90 days postoperatively, arrhythmias occurred in 1 patient (0.4%) who received a perioperative statin, 39 patients (4.0%) who did not receive statins (P = .003), and 24 patients (4.2%) who were on outpatient statins (P = .005). This is 10-fold reduction in the relative risk of developing a postoperative arrhythmia within 90 days of arthroplasty and an absolute risk reduction of 3.6%.ConclusionTreating as few as 28 patients with perioperative simvastatin prevents one new cardiac arrhythmia within 90 days in statin-naïve patients undergoing TJA.     

Preoperative Risk Factor Screening Protocols in Total Joint Arthroplasty: A Systematic Review

BackgroundPreoperative optimization protocols targeting potentially modifiable risk factors could prove beneficial in reducing the rate of complications in lower extremity total joint arthroplasty (LE-TJA). We aimed to summarize the evidence on preoperative screening protocols targeting modifiable risk factors to assess their effect on postoperative outcomes following primary LE-TJA.MethodsA literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in August 2019. The bibliographies of relevant publications were searched for further applicable studies. Included studies were required to report at least one outcome including prosthetic joint infection/surgical site infection (PJI/SSI), hospital length of stay (LOS), disposition, 90-day emergency department visits, or hospital readmissions after implementation of an evidence-based preoperative optimization protocol targeting modifiable risk factors. Methodological quality of included studies was assessed using the methodological index for non-randomized studies (MINORS) criteria.ResultsA total of 8 retrospective cohort studies including 9915 patients were reviewed. Implementation of preoperative optimization protocols were associated with reductions in SSI (0.56% vs. 2.60%; RR 0.21 [95% CI 0.12 to 0.37]; P < .00001), hospital LOS, mean cost of care, and hospital readmission rates. The mean MINORS score for comparative studies was 16.285.ConclusionsImplementation and compliance with evidence-based preoperative protocols for optimization of modifiable risk factors is associated with overall improved outcomes following LE-TJA. SSI, hospital LOS, average total cost of care, and hospital readmission rates were favorable in those cohorts subjected to a preoperative intervention protocol. Future prospective studies are necessary for further refinement of preoperative optimization protocols and referral algorithms, without compromising patients’ access to surgery.Level of EvidenceIII, Systematic Review;     

Incidence,Risk Factors,and Clinical Implications of Pneumonia Following Total Hip and Knee Arthroplasty

Background

The purpose of this study is to determine the incidence, risk factors, and clinical implications of pneumonia following total joint arthroplasty (TJA).

Changes in Patient Satisfaction Following Total Joint Arthroplasty

BackgroundThe primary aim is to identify the degree to which patient satisfaction with the outcome of total hip arthroplasty (THA) or total knee arthroplasty (TKA) changes between 1 and 3 years from the procedure. The secondary aim is to identify variables associated with satisfaction.MethodsData were sourced from 2 prospective international, multicenter studies (919 THA and 450 TKA patients). Satisfaction was assessed by a 10-point numerical rating scale, at 1- and 3-year follow-up. Linear mixed-effects models were used to assess factors associated with satisfaction.ResultsFor the THA cohort, higher preoperative joint space width (odds ratio [OR] = 0.28; P = .004), pain from other joints (OR = 0.26; P = .033), and lower preoperative health state (OR = −0.02; P < .001) were associated with consistently lower levels of satisfaction. The model also showed that patients with preoperative anxiety/depression improved in satisfaction between 1 and 3 years (OR = −0.26; P = .031).For the TKA cohort, anterior (vs neutral or posterior) tibial component slope (OR = 0.90; P = .008), greater femoral component valgus angle (OR = 0.05; P = .012), less severe osteoarthritis (OR = −0.10; P < .001), and lower preoperative health state (OR = −0.02; P = .003) were associated with lower levels of satisfaction across the study period. In addition, patients with anterior tibial component slope improved in satisfaction level over time (OR = −0.33; P = .022).ConclusionChanges in satisfaction following THA and TKA are rare between 1- and 3-year follow-up. The findings of this study can be used to guide patient counseling preoperatively and to determine intervals of routine follow-up postoperatively.     

Surgeon Decision-Making for Individuals With Obesity When Indicating Total Joint Arthroplasty

BackgroundObesity is a risk factor for complications after total joint arthroplasty (TJA). This study analyzed the impact of individual surgeon demographics, financial concerns, and other factors in determining patient candidacy for TJA based on body mass index (BMI).MethodsA 21-question survey was approved by the American Association of Hip and Knee Surgeons Research Committee for distribution to its membership. Objective questions asked about surgeon or hospital BMI thresholds for offering TJA. Subjective questions asked about physician comfort discussing topics including obesity, bariatric surgery, and weight loss before TJA, as well as insurance and age considerations.ResultsFor TJA procedures, 49.9% of surgeons had a BMI cutoff at 40, 24.5% at 45, and 8.3% at 50. At a BMI cutoff of 40, 23.8% of surgeons felt their patient volume would be adversely affected, whereas at a BMI cutoff of 35, 50% of surgeons felt their patient volume would be adversely affected. Surgeons were more likely to not perform total hip arthroplasty on patients with morbid obesity than total knee arthroplasty (P = .037). Significantly more academic surgeons did not have cutoffs for total hip arthroplasty (P = .003) or total knee arthroplasty (P < .001) compared with all other practice settings.ConclusionThere are myriad factors that affect surgeon BMI thresholds for offering elective TJA including poor outcomes, hospital thresholds, financial considerations, and the well being of the patient. Further work should be performed to minimize the risks associated with TJA while providing the best possible care to patients with morbid obesity.     

Computer-Assisted Total Knee Arthroplasty for Arthritis With Extra-articular Deformity

Forty extra-articular deformities (22 femoral and 18 tibial) in 34 patients (mean age, 63.1 years) were studied. Mean coronal extra-articular deformity was 9.3°; mean preoperative limb alignment was 166.7°. Three limbs underwent simultaneous corrective osteotomy; the rest were treated with intra-articular correction during computer-assisted total knee arthroplasty (TKA). Mean postoperative limb alignment was 179.1°. At a mean follow-up of 26.4 months, the Knee Society knee score improved from a mean preoperative score of 49.7 to 90.4 points postoperatively; function score improved from 47.3 to 84.9 points. Computer-assisted TKA is a useful alternative to conventional TKA for knee arthritis with extra-articular deformity where accurate restoration of limb alignment may be challenging because of the presence of a deformed tibia or femur or in the presence of hardware.     

Factors Associated With Early Return to Driving Following Total Joint Arthroplasty

BackgroundPatients often ask when they can safely return to driving a car following total joint arthroplasty (TJA). Most prior research has relied on driving simulators. Our study sought to learn more about real-world patient experiences in returning to driving after total knee arthroplasty (TKA) or total hip arthroplasty (THA).MethodsOur institutional total joint registry was used to identify living patients aged 18-85 who underwent primary TKA or primary THA for a primary diagnosis of osteoarthritis between January 1, 2019 and December 31, 2019. Patients who had undergone multiple TJA operations in 2019 or had a primary mailing address outside of the United States were excluded. Ultimately 2508 eligible TJA patients received a survey by mail.ResultsA total of 1128 of 2508 eligible patients (45%) completed surveys and returned them by mail. After 121 surveys were discarded for incompletion, inconsistency, or limited preoperative driving volume, 1007 patients were included in our study. Among these patients, 99% returned to driving postoperatively, with 23% returning within 2 weeks, and 88% returning within 6 weeks. Factors associated with the odds of a patient returning to driving within 2 weeks included laterality, gender, postoperative confidence, postoperative comfort, and surgeon advice. Ten patients (1%) have been involved in a car accident postoperatively.ConclusionAlmost all patients returned to driving postoperatively without being involved in a car accident. Gender, laterality, patient confidence, and comfort as well as surgeon advice were significantly associated with the odds of a patient returning to driving within 2 weeks postoperatively.     

Computer-Assisted Total Knee Arthroplasty for Significant Tibial Deformities

Computer-assisted total knee arthroplasty has been demonstrated to provide reproducible limb mechanical alignment within 3° from the neutral mechanical axis. However, restoring proper implant and extremity alignment remains a significant challenge with proximal tibial deficiencies. In this prospective study, we describe the use of computer navigation to quantify the amount of bone loss on the medial or lateral tibial plateau and the use of these data to assess the need for augmentation with metallic tibial wedges. In this study, we demonstrate that computer-assisted total knee arthroplasty in patients with significant tibial deformities can accurately measure severe tibial deformities, predict tibial augment thickness, and provide excellent mechanical alignment and restore the joint line without excessive bony resection, repeated osteotomies, and repeated augment trialing.     

Assessment of a Satisfaction Measure for Use After Primary Total Joint Arthroplasty

BackgroundPatient satisfaction after total hip (THA) and total knee arthroplasty (TKA) is a core outcome selected by the Outcomes Measurement in Rheumatology. Up to 20% of THA/TKA patients are dissatisfied. Improving patient satisfaction is hindered by the lack of a validated measurement tool that can accurately measure change.MethodsThe psychometric properties of a proposed satisfaction instrument, consisting of 4 questions rated on a Likert scale, scored 1-100, were tested for validity, reliability, and sensitivity to change using data collected between 2007 and 2011 in an arthroplasty registry.ResultsWe demonstrated construct validity by confirming our hypothesis; satisfaction correlated with similar constructs. Satisfaction correlated moderately with pain relief (TKA ρ = 0.61, THA ρ = 0.47) and function (TKA ρ = 0.65, THA ρ = 0.51) at 2 years; there was no correlation with baseline/preoperative pain/function values, as expected. Overall Cronbach’s alpha >0.88 confirmed internal consistency. Test-retest reliability with weighted kappa ranged 0.60-0.75 for TKA and 0.36-0.56 for THA. Hip disability and Osteoarthritis Outcome Score/Knee injury and Osteoarthritis Outcome Scores quality of life improvement (>30 points) corresponds to a mean satisfaction score of 93.2 (standard deviation, 11.5) after THA and 90.4 (standard deviation, 13.8) after TKA, and increasing relief of pain and functional improvement increased the strength of their association with satisfaction. The satisfaction measure has no copyright and is available free of cost and represents minimal responder burden.ConclusionPatient satisfaction with THA/TKA can be measured with a validated 4-item questionnaire. This satisfaction measure can be included in a total joint arthroplasty core measurement set for total joint arthroplasty trials.     

Operative Time Affects Short-Term Complications in Total Joint Arthroplasty

Background

Increased operative time has been associated with increased complications after total joint arthroplasty (TJA). The purpose of the present study was to investigate the effect of operative time on short-term complications after TJA while also identifying patient and operative factors associated with prolonged operative times.

Preoperative Asymptomatic Leucocyturia and Early Prosthetic Joint Infections in Patients Undergoing Joint Arthroplasty

Prosthetic joint infection (PJI) is associated with a higher mortality, morbidity and economic costs. Although it is well known that the presence of urinary tract infection (UTI) is associated with PJI, few investigations evaluated the preoperative asymptomatic leukocyturia (ASL) and the possible relationship with early PJI. We reviewed the records of 739 patients performed primary joint arthroplasty. A total of 131 patients had preoperative ASL (17.7%) and 7 of 739 patients (0.9%) had early PJI. Preoperative ASL was not confirmed as a risk factor for early PJI on the multivariate regression analysis with an adjusted OR of 1.04 (P > 0.05). Therefore, it should not be considered as a reason for postponement of total joint arthroplasty.     

The Cost-Effectiveness of Silver-Impregnated Occlusive Dressings for Infection Prevention After Total Joint Arthroplasty

BackgroundProsthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty that exacts a substantial economic burden on the health-care system. This study used break-even analysis to investigate whether the use of silver-impregnated occlusive dressings is a cost-effective measure for preventing PJI after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).MethodsBaseline infection rates after TKA and THA, the cost of revision arthroplasty for PJI, and the cost of a silver-impregnated occlusive dressing were determined based on institutional data and the existing literature. A break-even analysis was then conducted to calculate the minimal absolute risk reduction needed for cost-effectiveness.ResultsThe use of silver-impregnated occlusive dressings would be economically viable at an infection rate of 1.10%, treatment costs of $25,692 for TKA PJI, and $31,753 for THA PJI and our institutional dressing price of $38.05 if it reduces infection rates after TKA by 0.15% (the number needed to treat [NNT] = 676) and THA by 0.12% (NNT = 835). The absolute risk reduction needed to maintain cost-effectiveness did not change with varying initial infection rates and remained less than 0.40% (NNT = 263) for infection treatment costs as low as $10,000 and less than 0.80% (NNT = 129) for dressing prices as high as $200.ConclusionThe use of silver-impregnated occlusive dressings is a cost-effective measure for infection prophylaxis after TKA and THA.     

No Difference in Total Episode-of-Care Cost Between Staged and Simultaneous Bilateral Total Joint Arthroplasty

Background

Due to concerns about higher complication rates, surgeons debate whether to perform simultaneous bilateral total joint arthroplasty (BTJA), particularly in the higher-risk Medicare population. Advances in pain management and rehabilitation protocols have called into question older studies that found an overall cost benefit for simultaneous procedures. The purpose of this study was to compare 90-day episode-of-care costs between staged and simultaneous BTJA among Medicare beneficiaries.

Optimal Length of Stay Following Total Joint Arthroplasty to Reduce Readmission Rates

BackgroundLength of stay (LOS) following total joint arthroplasty (TJA) continues to decrease. The effects of this trend on readmission risk and total cost are unclear. We hypothesize that optimal LOS following TJA minimizes index hospitalization, early readmission risk, and total cost.MethodsRetrospective data from the South Carolina Department of Revenue and Fiscal Affairs was reviewed for patients who underwent primary TJA in South Carolina from 2000 to 2015 (n = 172,760). Data for readmissions within 90 days were included. Severity of illness was estimated by Elixhauser score (EH). Index LOS is defined as the surgery and the subsequent hospital stay.ResultsPatients with more significant medical comorbidities (EH ≥ 4) had significantly longer LOS than healthier patients (4.0 vs 3.4 days, P < .001). Independent of EH, readmitted patients had a significantly longer index LOS than those never readmitted (4.3 vs 3.6 days, P < .001). For healthier patients (EH ≤ 3), each additional inpatient day increased readmission risk, while among sicker patients, staying 2 days vs 1 day was protective against readmission risk. Since 2000, the total index cost of TJA has doubled and average cost per inpatient day has tripled, but readmission rates remain essentially unchanged (7.4% to 7.0%).ConclusionIncreased LOS was associated with increased readmission risk. Patients with greater medical comorbidities stay longer to protect against readmission. Optimal LOS after TJA is highly influenced by the patient’s overall health. Despite a 300% increase in TJA daily cost, readmission rate has changed minimally over the last 15 years.