Hospital and Surgeon Reimbursement Trends for Femoral Neck Fractures Treated With Hip Hemiarthroplasty and Total Hip Arthroplasty

BackgroundThe economic impact of hip fractures on the health care system continues to rise with continued pressure to reduce unnecessary costs while maintaining quality patient care. This study aimed to analyze the trend in hospital charges and payments relative to surgeon charges and payments in a Medicare population for hip hemiarthroplasty and total hip arthroplasty (THA) for femoral neck fracture.MethodsThe 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 32,340 patients who underwent hemiarthroplasty and 4323 patients who underwent THA for femoral neck fractures between 2005 and 2014. Two values were calculated: (1) charge multiplier (CM, ratio of hospital to surgeon charges), and (2) payment multiplier (PM, ratio of hospital to surgeon payments). Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index (CCI), length of stay (LOS), 90-day and 1-year mortality, CM, and PM were evaluated.ResultsHospital charges were significantly higher than surgeon charges and increased substantially for hemiarthroplasty (CM of 13.6 to 19.3, P < .0001) and THA (CM of 9.8 to 14.9, P = .0006). PM followed a similar trend for both hemiarthroplasty (14.9 to 20.2; P = .001) and THA (11.9 to 17.4; P < .0001). LOS decreased significantly for hemiarthroplasty (3.78 to 3.37d; P < .0001) despite increasing CCI (6.36 to 8.39; P = .018), whereas both LOS (3.71 to 3.79 days; P = .421) and CCI (5.34 to 7.08; P = .055) remained unchanged for THA.ConclusionHospital charges and payments relative to surgeon charges and payments have increased substantially for hemiarthroplasty and THA performed for femoral neck fractures.     

Day of Surgery Affects Length of Stay and Charges in Primary Total Hip and Knee Arthroplasty

Background

Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Alcohol Withdrawal Is Associated With Worse Outcomes in Patients Undergoing Primary Total Knee or Total Hip Arthroplasty

BackgroundAlcohol withdrawal (AW) syndrome is an independent risk factor for postoperative complications. This study aims to evaluate the influence of AW on perioperative outcomes in patients who underwent primary total knee (TKA) or total hip arthroplasty (THA).MethodsWe used the National Inpatient Sample database to identify patients undergoing TKA/THA from 2003 to 2014. The primary exposure of interest was AW. Multivariable adjusted models were used to evaluate the association of AW with in-hospital medical complications, surgical complications, mortality, cost, and length of stay (LOS) in patients undergoing TKA/THA.ResultsThere were 2,971,539 adult hospitalizations for THAs and 6,367,713 hospitalizations for TKAs included in the present study, among which 0.14% of AW for THA patients and 0.10% of AW for TKA patients. Multivariable adjustment analysis suggested that AW was associated with an increased risk of medical complications (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.79-2.42, P < .0001), surgical complications (OR 1.75, 95% CI 1.51-2.03, P < .0001), and had 4.79 times increase of in-hospital mortality, 26% increase of total cost, and 53% increase of LOS in THA procedures. For TKA procedures, AW was also associated with increased risk of medical complications (OR 3.14, 95% CI 2.78-3.56, P < .0001), surgical complications (OR 2.07, 95% CI 1.82-2.34, P < .0001) and 4.24 times increase of in-hospital mortality, 29% increase of total cost, and 58% increase of LOS after multivariable adjustment.ConclusionAW is associated with increased risk of in-hospital mortality, medical and surgical complications. Proactive surveillance and management of AW may be important in improving outcomes in patients who underwent THA and TKA procedure.     

Increased Patient-Level Payment After Removal of Total Knee Arthroplasty From the Inpatient-Only List

BackgroundIn January 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the Inpatient Only (IPO) list. This study aimed to compare patient-level payments in TKA cases with a length of stay (LOS) <2 midnights before and after removal of TKA from IPO list.MethodsIn this retrospective cohort study, all Medicare patients who received a primary elective TKA from 2016-2019 with a LOS <2 midnights at an academic tertiary center were identified. Total and itemized charges and patient-level payments were compared between eligible TKA cases performed in 2016-2017 and those in 2018-2019. There were 351 eligible TKA cases identified: 151 in 2016-2017 and 200 in 2018-2019.ResultsThe percentage of patients making any out-of-pocket payment increased in 2018-2019 from 2016-2017 (51.0% versus 10.6%), as did median patient-level payment ($7.30 [range, $0.00-$3,389] versus $0.00 [range, $0.00-$1,248], P < .001 for both). A greater proportion of patients in 2018-2019 paid $1-$50 than in 2016-2017 (37.5% versus 1.3%, P < .001) with no change in the proportion of patients who made payments >$50. Total charges were less in 2018-2019 than in 2016-2017 (P = .001). Charges for drugs, laboratory tests, admissions/floor, and therapies decreased in 2018-2019, whereas charges for the operating room and radiology increased (P < .001 for all).ConclusionPatients receiving outpatient TKA in 2018-2019 were more likely to have out-of-pocket payments than patients with comparable hospital stay who were designated as inpatients, although most of these payments were less than $50.     

More Patients Are Being Discharged Home After Total Knee Arthroplasty,However Rates Vary Between Large Databases

BackgroundThere have been significant advancements in perioperative care for total knee arthroplasty (TKA). It is essential to quantify the impact of efforts to better optimize patients and deliver care. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), and complications.MethodsPatients undergoing primary TKA were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases using procedural codes. Patients were classified as being discharged home or not home (skilled nursing facility, acute rehab, other non-home destinations). Changes in discharge destination, LOS, comorbidity burden, readmissions, and reoperation were assessed.ResultsIn total, 254,195 ACS NSQIP patients underwent TKA, with an increase in home discharge from 67.2% in 2011 to 85.3% in 2017 (P < .0001). There were 178,071 TKA patients in the Humana database and home discharge increased from 62.1% in 2007 to 74.7% in 2016 (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and non-home going patients. Home going patients had a decrease in 30-day readmissions (ACS NSQIP: 2011: 3.6%, 2017: 2.7%, P = .001; Humana: 2007: 4.0%, 2016: 2.4%, P < .0001).ConclusionPatients undergoing TKA were discharged home more often, had shorter LOS, and had significantly lower readmission rates, despite an increasingly comorbid patient population. It is likely that these improvements in postoperative care have resulted in significant cost savings, for both payers and hospitals. The efforts necessary to create and maintain such improvements, as well as the source of data, should be considered when changes to reimbursement are being evaluated. The metrics studied in this paper should provide a comparison for further improvement with continued transition to bundle payments and transition to outpatient surgery with removal of TKA from the inpatient-only list.     

Home Discharge Has Increased After Total Hip Arthroplasty,However Rates Vary Between Large Databases

BackgroundThere have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA.MethodsPatients undergoing primary THA were identified using International Statistical Classification of Diseases and Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed.ResultsIn ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 (P < .0001). In Humana, 84,832 THA patients were identified, with an increase in home discharge from 56.6% to 72.8% (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and nonhome going patients. Patients discharged home had a decrease in readmissions in both databases.ConclusionPatients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.     

Does Productivity-Based Physician Compensation Affect Surgical Rates for Elective Arthroplasty Surgery?

BackgroundSurgeon compensation models could potentially influence the utilization of elective procedures. We assessed whether transitioning from salaried to a relative value unit (RVU) productivity-based physician compensation model changed the surgical rate and patient selection in elective total hip and knee arthroplasty (THA and TKA) procedures.MethodsOur institution transitioned from salaried to RVU productivity-based reimbursement in July 2016. We performed a retrospective analysis on patients undergoing primary THA and TKA from July 2014 to July 2018 before and after the transition (salary period n = 820; RVU period n = 1188). Beta regression was used to determine the reimbursement structure as a predictor of surgery. The surgical rate was defined as the number of primary THA and TKA procedures per reimbursement period divided by all arthroplasty and osteoarthritis outpatient clinic encounters.ResultsThere was a surgical rate of 15.8% (95% confidence interval [CI] 13.8%-17.8%) THA and 16.7% (95% CI 15.1%-18.1%) TKA procedures during RVU reimbursement compared to 11.1% (95% CI 9.8%-12.8%) THA and 11.7% (95% CI 10.5%-12.8%) TKA procedures during the salaried period (P < .001). The adjusted odds of undergoing a THA or TKA procedure increased in the RVU compared to the salaried model (THA odds ratio 1.48, 95% CI 1.43-1.53; TKA odds ratio 1.50, 95% CI 1.46-1.55; P < .001). There were no significant differences in patient age, gender, race, body mass index, or Charlson Comorbidity Index in salaried vs RVU productivity periods (P > .05 for all covariates).ConclusionsProductivity-based physician compensation may encourage higher rates of elective arthroplasty procedures without broadening patient selection.     

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.     

In a Bundled Payment Model,the Costs Associated With Total Joint Replacement in Those Aged Older Than 80 Years Are Significantly Greater

BackgroundThe number of octogenarians requiring a total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) will rise disproportionally in the coming decade. Although outcomes are comparable with younger patients, management of these older patients involves higher medical complexity at a greater expense to the hospital system. The purpose of this study was to compare the cost of care for primary THA and TKA in our bundled care patients aged ≥80 years to those aged 65-80 years.MethodsA retrospective review of primary TKA (n = 641) and THA (n = 1225) cases from 2013 to 2017 was performed. Patient demographic and admission cost data were collected. Patients were grouped based on surgery type (ie, elective or nonelective THA/TKA) and age group (ie, older [≥80 years old] or younger [65-80 years old]). Multivariate regression analyses were used to account for demographic differences.ResultsElective primary THA in the older cohort (n = 157) cost 24.5% more than the younger cohort (n = 1025) (P < .0001). Elective primary TKA cases in the older cohort (n = 87) cost 17.0% more than the younger cohort’s (n = 554) (P < .0001). For nonelective THA cases, the older cohort’s (n = 29) episodes cost 39.1% more than the younger cohort (n = 14) (P < .0001). When comparing the <80 elective THA cohort (n = 1025) to the ≥90 cohort (n = 10), the cost difference swelled to 58.7% (P < .0001).ConclusionAlthough primary THA and TKA in ≥80-year-old patients yield similar outcomes, this study demonstrates that the additional measures required to care for older patients and ensure successful outcomes cost significantly more. Consideration should be given to age as a factor in determining reimbursement in a bundled payment system to reduce the incentive to restrict care to elderly patients.     

Free Falling: Declining Inflation-Adjusted Payment for Arthroplasty Surgeons

BackgroundOver the past decade, there have been ongoing concerns over declining surgeon compensation for lower extremity arthroplasty. We aimed to determine changes in surgeon payment, patient charges, and overall reimbursement rates for patients undergoing unicompartmental arthroplasty (UKA) and both primary and revision total knee (TKA) and hip (THA) arthroplasty.MethodsUsing Medicare data from 2012 to 2017, we determined inflation-adjusted changes in annual surgeon payment (professional fee), patient charges, and reimbursement rate (payment-to-charge ratio) for UKA and primary/revision TKA and THA. Both nonweighted and weighted (by procedure frequency/volume) means were calculated.ResultsInflation-adjusted surgeon payment decreased for all procedures analyzed, with primary TKA (?17%) and THA (?11%) falling the most. Payment for UKA increased the most (+30%). There was a small increase in charges for THA revision (+2.2%, +2.1%, and +3.2% for acetabulum only, femur only, and both components, respectively). Charges for primary TKA (?3.7%) and THA (?1.5%) decreased slightly. The reimbursement rate for all procedures fell with UKA (?15%), TKA (?14%), and THA (?10%) falling the most. After weighting by procedure frequency/volume and combining all surgeries, average charges fell slightly (?0.7%), whereas surgeon payment (?13%) and reimbursement rate (?12%) fell more sharply.ConclusionAlthough patient charges have grown in pace with the inflationary rate for primary and revision TKA and THA, surgeon payment and reimbursement rates have fallen sharply. The orthopedic community needs to be aware of these financial trends to communicate to payers and health care policy makers the importance of protecting a sustainable payment infrastructure.     

The Impact of Arthroplasty Fellowship Training on Total Joint Arthroplasty: Comparison of Peri-Operative Metrics between Fellowship-Trained Surgeons and Non-Fellowship-Trained Surgeons

BackgroundWe sought to identify differences between total joint arthroplasties (TJAs) performed by adult reconstruction fellowship-trained surgeons (FT) than non-fellowship-trained surgeons (NFT).MethodsA single-institution database was utilized to identify patients who underwent elective TJA between 2016 and 2019.ResultsIn total, 16,882 TJAs were identified: 9111 total hip arthroplasties (THAs) and 7771 total knee arthroplasties (TKAs). Patients undergoing THA by FT surgeons were older (63.11 vs 61.84 years, P < .001), more likely to be white, insured by Medicare, and less likely to be active smokers (P < .0001). Both surgical time (90.03 vs 113.1 minutes, P < .0001) and mean length of stay (LOS) (1.85 vs 2.72 days, P < .0001) were significantly shorter for THAs performed by FT surgeons than NFT surgeons. A significantly greater percentage of patients were discharged home after THA by FT surgeons than NFT surgeons (88.7% vs 85.2%, P = .002). FT patients were quicker to mobilize with therapy and required 25% less opioids. TKAs performed by FT surgeons were associated with shorter surgical times (87.4 vs 94.92 minutes, P < .0001), LOS (2.62 vs 2.84 days, P < .0001), and nearly 19% less opioid requirement in the peri-operative period. In addition to higher Activity Measure for Post-Acute Care scores associated with FT surgeons after TKA, a significantly greater percentage of patients were discharged home after TKA by FT surgeons than NFT surgeons (83.97% vs 80.16%, P < .001).ConclusionFor both THA and TKA, patients had significantly shorter surgical times, LOS, and required less opioids when their procedure was performed by FT surgeons compared to NTF surgeons. Patients who had their TJA performed by a FT surgeon achieved higher Activity Measure for Post-Acute Care scores and were discharged home more often than NFT surgeons. In an era of value-based care, more attention should be paid to the patient outcomes and financial implications associated with arthroplasty fellowship training.Level III EvidenceRetrospective Cohort Study.     

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.     

An Analysis of Centers for Medicare & Medicaid Service Payment in Maryland: Can a Global Budget Revenue Model Save Money in Lower Extremity Arthroplasty?

Background

Maryland is the only state utilizing the Global Budget Revenue (GBR) model to reduce costs. The purpose of this study is to evaluate whether the GBR payment model effectively reduced the following: (1) costs of inpatient hospital stays; (2) post-acute care costs; (3) lengths of stay (LOS); (4) readmission rates; and (5) discharge disposition in patients who underwent primary total hip and knee arthroplasty (THA and TKA).

Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty

BackgroundThere is increasing focus on highlighting disparities in both access to and equity of care in orthopedics and understanding the impact disparities have on patient health. The purpose of the present study is to evaluate socioeconomic-related factors affecting whether a patient undergoes total hip arthroplasty (THA) after a diagnosis of osteoarthritis.MethodsFrom 2011 to 2018, patients ≥40 years of age diagnosed with hip osteoarthritis were identified in the New York Statewide Planning and Research Cooperative System, a comprehensive all-payer database collecting preadjudicated claims in New York State. International Classification of Diseases, Ninth Revision/Tenth Revision codes were used to identify the initial diagnosis and subsequent THA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of undergoing THA.ResultsOf 142,681 hip osteoarthritis diagnoses, 48.6% proceeded to THA. Compared to non-Hispanic white patients, Asian (odds ratio [OR] 0.65, P < .0001), Black (OR 0.51, P < .0001), and “Other” race (OR 0.54, P < .0001) had lower odds of THA. Hispanic patients (OR 0.55, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.83, P < .0001), Medicaid (OR 0.49, P < .0001), Self-pay (OR 0.78, P < .0001), and workers’ compensation (OR 0.71, P < .0001) had lower odds of THA. Having one or more Charlson Comorbidity Index (OR 0.45, P < .0001) was associated with lower odds of THA, as was increased social deprivation (OR 0.99, P < .0001).ConclusionTHA is associated with disparities among race, gender, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.     

Hospital Revenue,Cost, and Contribution Margin in Inpatient Versus Outpatient Primary Total Joint Arthroplasty

BackgroundRemoval of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty.MethodsWe reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-squared tests.ResultsAmong Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (P < .001), although there was no statistical significance difference between cohorts for TKA (P = .501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (P < .001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (P < .001).ConclusionOur analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care.Level III EvidenceRetrospective Cohort Study.     

Psychological Distress Independently Predicts Prolonged Hospitalization After Primary Total Hip and Knee Arthroplasty

BackgroundThe purpose of this study was to investigate the effect of psychological distress on hospital length of stay (LOS) in joint arthroplasty (TJA).MethodsA retrospective review of 863 patients who underwent primary, unilateral TJA at a single tertiary academic center was performed. Two groups were compared: patients with or without psychological distress defined using the Short Form-12 mental component summary. The primary outcome was the rate of hospital LOS exceeding 2 days. Secondary outcomes were rates of in-hospital complications and 90-day emergency room visits and readmissions. Univariate and multivariate logistic regression analyses were performed.ResultsThe prevalence of psychological distress was 23%. The mean LOS was 2.44 days. Patients with psychological distress were younger (P < .0001) and more likely to have depression (P < .0001), lower educational attainment (P < .0001), smoke tobacco (P = .003), be Hispanic/Latino (P = .001), live alone (P = .001), and have higher rates of nonprimary osteoarthritis (P < .0001). After adjusting for these differences, psychological distress was an independent predictor of LOS > 2 days (P = .049 and .006 for total hip arthroplasty [THA] and total knee arthroplasty [TKA], respectively). There were no differences in the rates of in-hospital complications (P = .913 and .782 for THA and TKA, respectively), emergency room visits (P = .467 and .355 for THA and TKA respectively), or readmissions (P = .118 and .334 for THA and TKA, respectively).ConclusionPsychological distress is an independent predictor of prolonged hospitalization after primary TJA. The Short Form-12 mental component summary is a good screening tool for identifying patients with poor mental health who may not be appropriate candidates for outpatient surgery. Efforts to address psychological distress before surgery are warranted.     

The Changing Characteristics of Arthroplasty Patients: A Retrospective Cohort Study

BackgroundTotal joint arthroplasty (TJA) is among the most common operations performed worldwide, with global volumes on the rise. It is important to understand if the characteristics of this patient population are changing over time for resource allocation and surgical planning. The purpose of this study is to examine how this patient population has changed between 2003 and 2017.MethodsA retrospective review of a prospective TJA database was conducted. Age, gender, body mass index, comorbidities, American Society of Anesthesiologists class, responsible diagnoses, and comorbidities were compared over 5-year intervals between 2003 and 2017. All patients undergoing primary, elective TJA were included.ResultsOverall, 17,138 TJAs were included. Mean body mass index increased over the study period for total hip arthroplasty (THA; 29.4-30.4 kg/m², P < .0001) and total knee arthroplasty (TKA; 32.0-3.1 kg/m², P < .0001) patients. THA patients were significantly younger in more recent years (68.0-66.8 years old, P = .0026); this trend was not observed among TKA patients. Over the study period, a significantly higher proportion of patients were American Society of Anesthesiologists class III/IV for THA (50.5%-72.3%) and TKA (57.5%-80.7%) (P < .00001). Prevalence of common comorbidities did not change significantly.ConclusionThe key findings of this retrospective analysis of a large prospective database are that patients undergoing TJA are becoming younger and more obese. It is unclear whether patients are becoming more medically complex. These trends paint a concerning picture of a population that is increasingly complex, and may require a greater allocation of resources in the future.Level of EvidenceLevel III, retrospective cohort study.     

Length of Stay After Joint Arthroplasty is Less Than Predicted Using Two Risk Calculators

BackgroundPredicting the length of stay (LOS) after total joint arthroplasty (TJA) has become more important with their recent removal from inpatient-only designation. The American College of Surgeons (ACS) National Surgical Quality Improvement Program surgical risk calculator and the CMS’ diagnosis-related group (DRG) calculator are two common LOS predictors. The aim of our study was to determine how our actual LOS compared with those predicted by both the ACS and DRG.Methods99 consecutive TJA (49 hips and 50 knee procedures) were reviewed in Medicare-eligible patients from four fellowship-trained arthroplasty surgeons. Predicted LOS was calculated using the DRG and ACS risk calculators for each patient using demographics, medical histories, and comorbidities. LOS was compared between the predicted and the actual LOS for both total hip arthroplasty (THA) and total knee arthroplasty (TKA) using paired t-tests.ResultsActual LOS was shorter in the THA group vs the TKA group (1.29 days vs 1.46 days, P < .05). The actual LOS of patients at our institution was significantly shorter than both DRG and ACS predictions for both THA and TKA (P < .05). In both the THA and TKA patients, the actual LOS (1.29 and 1.46 day) was significantly shorter than the DRG-predicted LOS (2.15 and 2.15 days) which was significantly shorter than the ACS-predicted LOS (2.9 and 3.14 days).ConclusionWe found the actual LOS was significantly shorter than that predicted by both the DRG and ACS risk calculators. Current risk calculators may not be accurate for contemporary fast-track protocols and newer tools should be developed.     

Wound Complications Are Affected by Different Skin Closure Methods in Primary Hip and Knee Arthroplasty

BackgroundThere is a lack of consensus on optimal skin closure and dressing strategies to reduce early wound complication rates after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsAll 13,271 patients at low risk for wound complications undergoing primary, unilateral THA (7,816), and TKA (5,455) for idiopathic osteoarthritis at our institution between August 2016 and July 2021 were identified. Skin closure, dressing type, and postoperative events related to wound complications were recorded during the first 30 postoperative days.ResultsThe need for unscheduled office visits to address wound complications was more frequent after TKA than THA (2.74 versus 1.78%, P < .001), and after direct anterior versus posterior approach THA (2.94 versus 1.39%, P < .001). Patients who developed a wound complication, had a mean of 2.9 additional office visits. Compared to the use of topical adhesives, skin closure with staples had the highest risk of wound complications (odds ratio 1.8 [1.07-3.11], P = .028). Topical adhesives with polyester mesh had higher rates of allergic contact dermatitis than topical adhesives without mesh (1.4 versus 0.5%, P < .0001).ConclusionWound complications after primary THA and TKA were often self-limited but increased burden on the patient, surgeon, and care team. These data, which suggest different rates of certain complications with different skin closure strategies, can inform a surgeon on optimal closure methods in their practice. Adoption of the skin closure technique with the lowest risk of complications in our hospital would conservatively result in a reduction of 95 unscheduled office visits and save a projected $585,678 annually.