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.     

Increased Complications and Cost Associated With Hip Arthroplasty for Femoral Neck Fracture: Evaluation of 576,119 Medicare Patients Treated With Hip Arthroplasty

BackgroundThe benefit of total hip arthroplasty (THA) for treatment of osteoarthritis (OA) and femoral neck fractures (FNFs) in the geriatric population is well established. We compare perioperative complications and cost of THA for treatment of OA to hemiarthroplasty (HA) and THA for treatment of FNF.MethodsData from the Centers for Medicare & Medicaid Services were used to identify all patients 65 years and older undergoing primary hip arthroplasty between 2013 and 2017. Patients were divided into 3 cohorts: THA for OA (n = 326,313), HA for FNF (n = 223,811), and THA for FNF (n = 25,995). Generalized regressions were used to compare group mortality, 90-day readmission, thromboembolic events, and 90-day episode costs, controlling for age, gender, race, and comorbidities.ResultsCompared to patients treated for OA, FNF patients were older and had significantly more comorbidities (all P < .001). Even among the youngest age group (65-69 years) without comorbidities, FNF was associated with a greater risk of mortality at 90 days (THA-FNF odds ratio [OR] 9.3, HA-FNF OR 27.0, P < .001), 1 year (THA-FNF OR 7.8, HA-FNF OR 19.0, P < .001) and 5 years (THA-FNF hazard ratio 4.5, HA-FNF hazard ratio 10.0, P < .001). The average 90-day direct cost was $12,479 and $14,036 greater among THA and HA for FNF respectively compared to THA for OA (all P < .001).ConclusionAmong Centers for Medicare & Medicaid Services hip arthroplasty patients, those with an FNF had significantly higher rates of mortality, thromboembolic events, readmission, and greater direct cost. Reimbursement models for arthroplasty should account for the distinctly different perioperative complication and resource utilization for FNF patients.     

Cemented Vs Cementless Femoral Fixation for Total Hip Arthroplasty After Displaced Femoral Neck Fracture: A Nationwide Analysis of Short-Term Complications and Readmission Rates

BackgroundActive patients with displaced femoral neck fractures are often treated with total hip arthroplasty (THA). However, optimal femoral fixation in these patients is controversial. The purpose of this study was to compare early complication and readmission rates in patients with hip fracture treated with THA receiving cemented vs cementless femoral fixation.MethodsThe National Readmissions Database was queried to identify patients undergoing primary THA for femoral neck fracture from 2016 to 2017. Postoperative complications and unplanned readmissions at 30, 90, and 180 days were compared between patients treated with cemented and cementless THA. Univariate and multivariate analyses were performed to compare differences between groups and account for confounding variables.ResultsOf 17,491 patients identified, 4427 (25.3%) received cemented femoral fixation and 13,064 (74.7%) cementless. The cemented group was significantly older (77.2 vs 71.1, P < .001), had more comorbidities (Charlson comorbidity index: 4.44 vs 3.92, P < .001), and had a greater proportion of women (70.5% vs 65.2%, P < .001) compared with the cementless group. On multivariate analysis, cemented fixation was associated with reduced rates of periprosthetic fracture (odds ratio: 0.052, 95% confidence interval: 0.003-0.247, P = .004) at 30 days but similar readmission rates at 30, 90, and 180 days (odds ratio range: 1.012-1.114, P > .05) postoperatively compared with cementless fixation. Cemented fixation was associated with greater odds of medical complications at 180 days postoperatively (odds ratio:: 1.393, 95% confidence interval: 1.042-1.862, P = .025).ConclusionCemented femoral fixation was associated with a lower short-term incidence of periprosthetic fractures, higher incidence of medical complications, and equivalent unplanned readmission rates within 180 days postoperatively compared with cementless fixation in patients undergoing THA for femoral neck fracture.Level of EvidenceLevel III.     

Compensated Cirrhosis Is Associated With Increased Risk of Complications Following Total Hip Arthroplasty in a Large Medicare Database

BackgroundThe aim of this study is to evaluate medical and surgical complications of liver cirrhosis patients following total hip arthroplasty (THA), with attention to different etiologies of cirrhosis and their financial burden following THA.MethodsIn total, 18,321 cirrhotics and 722,757 non-cirrhotics who underwent primary elective THA between 2006 and 2013 were identified from a retrospective database review. This cohort was further subdivided into 2 major etiologies of cirrhosis (viral and alcoholic cirrhosis) and other cirrhotic etiology. Cirrhotics were compared to non-cirrhotics for hospital length of stay, 90-day mean total charges and reimbursement, hospital readmission, and major medical and arthroplasty-specific complications.ResultsCirrhosis was associated with increased rates of major medical complications (4.3% vs 2.4%; odds ratio [OR] 1.20, P < .001), minor medical complications, transfusion (3.4% vs 2.1%; OR 1.16, P = .001), encephalopathy, disseminated intravascular coagulation, and readmission (13.5% vs 8.6%; OR 1.18, P < .001) within 90 days. Cirrhosis was associated with increased rates of revision, periprosthetic joint infection, hardware failure, and dislocation within 1 year postoperatively (3.1% vs 1.6%; OR 1.37, P < .001). Cirrhosis independently increased hospital length of stay by 0.14 days (P < .001), and it independently increased 90-day charges and reimbursements by $13,791 (P < .001) and $1707 (P < .001), respectively. Viral and alcoholic cirrhotics had higher rates of 90-day and 1-year complications compared to controls—other causes only had higher rates of 90-day medical complications, encephalopathy, readmission, and 1-year revision, hardware failure, and dislocation compared to controls.ConclusionCirrhosis, especially viral and alcoholic etiologies, is associated with higher risk of early postoperative complications and healthcare utilization following elective THA.     

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.     

Target Price Adjustment for Hip Fractures Is Not Sufficient in the Bundled Payments for Care Improvement Initiative

BackgroundUnder the Bundled Payments for Care Improvement (BPCI) initiative, the Centers for Medicare and Medicaid Services (CMS) adjusts the target price for total hip arthroplasty (THA) based upon the historical proportion of fracture cases. Concerns exist that hospitals that care for hip fracture patients may be penalized in BPCI. The purpose of this study is to compare the episode-of-care (EOC) costs of hip fracture patients to elective THA patients.MethodsWe reviewed a consecutive series of 4096 THA patients from 2015 to 2018. Patients were grouped into elective THA (n = 3686), fracture THA (n = 176), and hemiarthroplasty (n = 274). Using CMS claims data, we compared EOC costs, postacute care costs, and performance against the target price between the groups. To control for confounding variables, we performed a multivariate analysis to identify the effect of hip fracture diagnosis on costs.ResultsElective THA patients had lower EOC ($18,200 vs $42,605 vs $38,371; P < .001) and postacute care costs ($4477 vs $28,093 vs $23,217; P < .001) than both hemiarthroplasty and THA for fracture. Patients undergoing arthroplasty for fracture lost an average of $23,122 (vs $1648 profit for elective THA; P < .001) with 91% of cases exceeding the target price (vs 20% for elective THA; P < .001). In multivariate analysis, patients undergoing arthroplasty for fracture had higher EOC costs by $19,492 (P < .001).ConclusionPatients undergoing arthroplasty for fracture cost over twice as much as elective THA patients. CMS should change their methodology or exclude fracture patients from BPCI, particularly during the COVID-19 pandemic.     

Patients With Multiple Sclerosis are at Increased Risk for Postoperative Complications Following Total Hip and Knee Arthroplasty

BackgroundMultiple sclerosis (MS) is a chronic inflammatory demyelinating disease affecting the central nervous system. Patients with MS are living longer due to improved medical therapy and thus the demand for arthroplasty in this population will increase. The objective of this study is to evaluate MS as a potential risk factor for postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsPatients with a diagnosis of MS who underwent THA or TKA from 2005 to 2014 were identified in a national insurance database. Rates of death, hospital readmission, emergency room visits, infection, revision, and dislocation (for THA) or stiffness (for TKA) were calculated, in addition to cost and length of stay. MS patients were then compared to a matched control population.ResultsIn total, 3360 patients who underwent THA and 6436 patients who underwent TKA with a history of MS were identified and compared with 10:1 matched control cohorts without MS. The MS group for both TKA and THA had significantly higher incidences of hospital readmission (THA odds ratio [OR] 2.05, P < .001; TKA OR 1.99, P < .001), emergency room visits (THA OR 1.41, P < .001; TKA OR 1.66, P < .001), and infection (THA OR 1.35, P = .001; TKA OR 1.32, P < .001). MS patients who underwent THA had significantly higher rates of revision (OR 1.35, P = .001) and dislocation (OR 1.52, P < .001). Diagnosis of MS was also associated with significantly higher costs and hospital length of stay for patients undergoing both TKA and THA.ConclusionA diagnosis of MS is associated with increased risk of postoperative complications and higher costs following both THA and TKA.     

Pigmented Villonodular Synovitis of the Hip in Patients Undergoing Total Hip Arthroplasty: A Retrospective Case-Controlled Analysis

BackgroundPigmented villonodular synovitis (PVNS) is a condition affecting larger joints such as the hip and knee. Little is known regarding the impact of PVNS on total hip arthroplasty (THA). Therefore, the aim of this study is to determine if patients with PVNS of the hip undergoing primary THA experience greater (1) in-hospital lengths of stay (LOS); (2) complications; (3) readmission rates; and (4) costs.MethodsPatients undergoing primary THA for PVNS of the hip from the years 2005 to 2014 were identified using a nationwide claims registry. PVNS patients were matched to a control cohort in a 1:5 ratio by age, gender, and various comorbidities. The query yielded 7440 patients with (n = 1240) and without (n = 6200) PVNS of the hip undergoing primary THA. Endpoints analyzed included LOS, complications, readmission rates, and costs. Multivariate logistic regression was used to determine odds ratios (OR) of developing complications. Welch’s t-tests were used to test for significance in LOS and cost between the cohorts. A P-value less than .001 was considered statistically significant.ResultsPVNS patients had approximately 8% longer in-hospital LOS (3.8 vs 3.5 days, P = .0006). PVNS patients had greater odds of (OR 1.60, P < .0001) medical and (OR 1.81, P < .0001) implant-related complications. Furthermore, PVNS patients were found to have higher odds (OR 1.84, P < .0001) of 90-day readmissions. PVNS patients also incurred higher day of surgery ($13,119 vs $11,983, P < .0001) and 90-day costs ($17,169 vs $15,097, P < .0001).ConclusionWithout controlling for global trends in LOS, complications, readmissions, or costs between 2005 and 2014, the findings of the study suggest that PVNS of the hip is associated with worse outcomes and higher costs following primary THA. The study is useful as orthopedic surgeons can use the study to educate patients of the complications which may occur following their hip surgery.     

Hip Arthroplasty Outcomes for Femoral Neck Fractures in Transplant Patients

BackgroundThe purpose of this study was to compare the short-term complications between transplant and nontransplant patients who undergo hip arthroplasty for femoral neck fractures (FNFs). Additionally, we sought to further compare the outcomes of total hip arthroplasty (THA) versus hemiarthroplasty (HA) within the transplant group.MethodsThis was a retrospective review utilizing the Nationwide Readmissions Database. Transplant patients were identified and stratified based on transplant type: kidney, liver, or other (heart, lung, bone marrow, and pancreas). Outcomes of interest included index hospitalization mortality, perioperative complications, length of stay, costs, hospital readmission, and surgical complications within 90 days of discharge.ResultsFrom 2010 to 2018, a total of 881,061 patients underwent THA or HA for FNFs, of which 2163 (0.2%) were transplant patients. When compared with nontransplant patients, all transplant patients had an increased risk of requiring blood transfusion (odds ratio [OR] = 1.51, P = .001), acute kidney injury (OR = 2.02, P < .001), and discharge to facility (OR = 1.67, P = .001) while having increased index hospitalization length of stay and costs. Liver and other transplant patients had an increased risk of readmission within 90 days (OR = 1.82, P < .001 and OR = 1.60, P = .014 respectively). Subgroup analysis for transplant patients comparing HA with THA demonstrated no differences in perioperative complication rates and decreased hospitalization length of stay and cost associated with THA.ConclusionIn this retrospective cohort study, transplant patients had an increased risk of requiring blood transfusions and acute kidney injury after hip arthroplasty for FNFs. There were no differences in short-term complications between transplant patients treated with HA versus THA.Level of evidence3 (Retrospective cohort study).     

Hospital Frailty Risk Score Predicts Adverse Events in Primary Total Hip and Knee Arthroplasty

BackgroundThe Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty.MethodsIn a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events.ResultsPatients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P < .001), readmission (9.6% vs 4.3%, P < .001), surgical complications (9.1% vs 1.8%, P < .001), internal complications (7.3% vs 1.1%, P < .001), other complications (24.4% vs 2.0%, P < .001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P < .001), and transfusion (10.4% vs 1.3%, P < .001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.46-3.09; P < .001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P < .001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P < .001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P < .001).ConclusionThe HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense.Level of EvidenceLevel III–retrospective cohort study.     

Rural Hospital Designation Is Associated With Increased Complications and Resource Utilization After Primary Total Hip Arthroplasty: A Matched Case-Control Study

BackgroundAs the prevalence of hip osteoarthritis increases, the demand for total hip arthroplasty (THA) has grown. It is known that patients in rural and urban geographic locations undergo THA at similar rates. This study explores the relationship between geographic location and postoperative outcomes.MethodsIn this retrospective cohort study, the Truven MarketScan database was used to identify patients who underwent primary THA between January 2010 and December 2018. Patients with prior hip fracture, infection, and/or avascular necrosis were excluded. Two cohorts were created based on geographic locations: urban vs rural (rural denotes any incorporated place with fewer than 2500 inhabitants). Age, gender, and obesity were used for one-to-one matching between cohorts. Patient demographics, medical comorbidities, postoperative complications, and resource utilization were statistically compared between the cohorts using multivariate conditional logistic regression.ResultsIn total, 18,712 patients were included for analysis (9356 per cohort). After matching, there were no significant differences in comorbidities between cohorts. The following were more common in rural patients: dislocation within 1 year (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.08-1.41, P < .001), revision within 1 year (OR 1.17, 95% CI 1.05-1.32, P = .027), and prosthetic joint infection (OR 1.14, 95% CI 1.04-1.34, P = .033). Similarly, rural patients had higher odds of 30-day readmission (OR 1.31, 95% CI 1.09-1.56, P = .041), 90-day readmission (OR 1.41, 95% CI 1.26-1.71, P = .023), and extended length of stay (≥3 days; OR 1.52, 95% CI 1.22-1.81, P < .001).ConclusionTHA in rural patients is associated with increased cost, healthcare utilization, and complications compared to urban patients. Standardization between geographic areas could reduce this discrepancy.     

Patterns and Costs of 90-Day Readmission for Surgical and Medical Complications Following Total Hip and Knee Arthroplasty

BackgroundUnplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications.MethodsWe performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories.ResultsAmong THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all).ConclusionReadmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.     

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.     

Iron Deficiency Anemia is Associated with Increased Early Postoperative Surgical and Medical Complications Following Total Hip Arthroplasty

BackgroundIron deficiency anemia (IDA) is a medical comorbidity commonly diagnosed in those undergoing primary total hip arthroplasty (THA). The authors sought to evaluate IDA as a risk factor for early postoperative complications following discharge and describe the hospital resource utilization of this patient population.MethodsPatients with a diagnosis of IDA who underwent THA from 2005 to 2014 were identified in a national insurance database. The rates of postoperative medical complications and surgery-related complications, as well as hospital readmission, emergency department visits, and death were calculated. Additionally, 90-day and day of surgery cost and length of stay were calculated. IDA patients were then compared to a 4:1 matched control population without IDA using a logistic regression analysis to control for confounding factors.ResultsIn total, 98,681 patients with a preoperative diagnosis of IDA who underwent THA were identified and compared to 386,724 controls. IDA was associated with increased risk of 30-day emergency department visits (odds ratio [OR] 1.35, P < .001) and 30-day readmission (OR 1.49, P < .001). IDA was also associated with an increased 90-day medical complication rate (cerebrovascular accident OR 1.11, P = .003; urinary tract infection OR 1.14, P < .001; acute renal failure OR 1.24, P < .001; transfusion OR 1.40, P < .001), as well as 1-year periprosthetic joint infection (OR 1.27, P < .001), revision (OR 1.22, P < .001), dislocation (OR 1.25, P < .001), and fracture (OR 1.43, P < .001). Patients with IDA accrued higher hospital charges ($27,658.27 vs $16,709.18, P < .001) and lower hospital reimbursement ($5509.90 vs $3605.59, P < .001).ConclusionPatients with preoperative IDA undergoing THA are at greater risk of experiencing early postoperative complications and have greater utilization of hospital resources.     

RAPT Scores Predict Inpatient Versus Outpatient Status and Readmission Rates After IPO Changes for Total Joint Arthroplasty: An Analysis of 12,348 Cases

BackgroundChanges to Medicare’s Inpatient Only List (IPO) and factors associated with the COVID pandemic have led to more total joint arthroplasty (TJA) patients to be designated as outpatient (OP). This potentially complicates postoperative care for patients with lower functional status and poor social support. These factors make the decision between OP versus inpatient (IP) designation particularly challenging for healthcare teams. The Risk Assessment and Prediction Tool (RAPT) was designed to indicate patient risk for needing posthospital discharge to facility and considers social and functional factors. The purpose of this study is to 1) evaluate the correlation of RAPT as a clinical tool to aid decision-making regarding OP versus IP for Total Hip and Knee Arthroplasty (THA and TKA), 2) assess the impact of recent changes to the IPO and the COVID pandemic on OP TJA readmission rates, and 3) determine whether 90-day readmissions are correlated with RAPT scores after OP TJA.MethodsWe identified all elective TKA and THA patients from 2015 through 2021 in our electronic health record at our large, urban, academic health system. Fracture patients were excluded. For those patients with available RAPT scores, we determined OP and IP designations, with IP defined as those with length-of-stay 2 midnights or more. We performed subanalysis of OP between same-day and next-day discharge. RAPT scores and readmission rates were compared at time points related to changes in the IPO: before TKA removal in 2018 (period A), from 2018 until THA removal in 2020 (Period B), and after January 1, 2020, inclusive of impact from the COVID pandemic (Period C).ResultsReviewed were 11,819 elective TKAs and 10,212 elective THAs. RAPT scores were available for 6,759 TKA patients and 5,589 THA patients. For both TKA and THA, RAPT scores between IP, same-day, and next-day discharged OP were significantly different across all time periods (P < .001). The percentage of OP designation increased across all time periods for TKA and THA. Over these same time periods, mean RAPT scores decreased significantly for both OP TKA and OP THA (P < .01). Concurrent with these changes were significant increases in OP THA 90-day readmission rates across Periods A and B (P = .010) as well as A and C (P = .006). Readmitted OP TKA had significantly lower RAPT scores than OP TKA without readmission during Period B (P < .001). Readmitted OP THA had significantly lower RAPT scores than those without readmission for all periods (P < .05). To facilitate clinical utility, median RAPT scores were also analyzed, and showed that RAPT scores for OP THA patients with readmission were 1 to 2 points lower for all time periods.ConclusionRAPT scores correlate with IP versus OP status for both TKA and THA and vary significantly with same-day versus next-day discharge. OP TJA RAPT scores may also help predict readmission, and counsel some patients away from OP surgery. Average RAPT scores of 10, 9, and 8 appeared to be separators for same day, next day, and inpatient stay. Changes to the IPO and COVID pandemic correlate with decrease in RAPT scores for both TKA and THA patients within all designations. In addition, a shift toward lower RAPT for OP TJA correlates with increased 90-day readmission rates for OP TJA. Taken together, these results suggest that patients with poorer function and worse social support systems are increasingly being driven toward OP surgery by these changes, which may play a role in increasing readmission rates. Social support and functional factors should be considered for OP elective TKA and THA. Further, any OP TJA value-based payment system must account for these variables.     

Total Hip Arthroplasty in Patients Who Have Respiratory Disease Who use Supplemental Home Oxygen

BackgroundThe purpose of this study is to investigate the association between supplemental home oxygen prior to surgery and both medical and surgical complications after primary elective total hip arthroplasty (THA) in patients who have respiratory disease (RD).MethodsThe Mariner database was used to identify patients who have RD who received primary elective THA from 2010 to 2020. The THA patient cohorts consisted of 20,872 patients who had RD prescribed home oxygen and 69,520 patients who had RD without home oxygen. For patients who had a diagnosis of RD and were prescribed supplemental home oxygen (O2) and those who were not, the rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were determined. Reimbursements and lengths of stay were also determined. Logistic regression analyses were utilized to compare both cohorts to matched cohorts without RD, as well as to each other directly.ResultsIn comparison to the matched control group, the RD with home oxygen group had a significantly higher rate of pneumonia (odds ratio [OR] 4.27, P < .0001), pulmonary embolism (OR 1.81, P < .0001), periprosthetic joint infection (OR 1.21, P < .0001), and periprosthetic fracture (OR 1.81, P = .001). The RD with home oxygen cohort also had a significantly higher incidence of pneumonia (OR 2.16, P < .0001), periprosthetic joint infection (OR 1.38, P < .0001), and periprosthetic fracture (OR 1.24, P = .009) compared to RD patients who did not have home oxygen.ConclusionSupplemental home oxygen use prior to surgery is associated with a significantly higher risk of postoperative medical and surgical complications after elective THA.     

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.     

Positive COVID-19 Diagnosis Following Primary Elective Total Joint Arthroplasty: Increased Complication and Mortality Rates

BackgroundThis study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19.MethodsA large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]).ResultsOf patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately.ConclusionPatients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.     

Implant-Related Complications Among Patients With Opioid Use Disorder Following Primary Total Hip Arthroplasty: A Matched-Control Analysis of 42,097 Medicare Patients

BackgroundOpioid use disorders (OUD) are a major cause of morbidity and mortality. The authors of this study hypothesize that patients who have an OUD will have greater relative risk of implant-related complications, periprosthetic joint infections (PJIs), readmission rates, and will incur greater costs compared to non-opioid use disorder (NUD) patients following primary total hip arthroplasty (THA).MethodsOUD patients who underwent a THA between 2005 and 2014 were identified and matched to controls in a 1:5 ratio according to age, sex, a comorbidity index, and various medical comorbidities yielding 42,097 patients equally distributed in both cohorts. Pearson’s chi-square analyses were used to compare patient demographics. Relative risk (RR) was used to analyze and compare risk of 2-year implant-related complications, 90-day PJIs, and 90-day readmission rates. Welch’s t-tests were used to compare day of surgery and 90-day episode-of-care costs between the cohorts. A P value less than .006 was considered statistically significant.ResultsOUD patients had higher incidences and risks of implant-related complications (11.99% vs 6.68%; RR, 1.74; P < .001), developing PJIs within 90 days (2.38% vs 1.81%; RR, 1.32; P = .001), and 90-day readmissions (21.49% vs 17.35%; RR, 1.23; P < .001). Additionally, the study demonstrated OUD patients incurred greater day of surgery ($14,384.30 vs $13,150.12, P < .0001) and 90-day costs ($21,183.82 vs $18,709.02, P < .0001) compared to controls.ConclusionAfter controlling for age, sex, a comorbidity index, and various medical complications, OUD patients are at greater risk to experience implant-related complications, PJIs, readmissions, and have greater costs following primary THA compared to non-OUD patients. This study should help orthopedic surgeons counsel their patients of potential complications which may arise following their primary THA.     

Total Hip Arthroplasty in Patients With Cerebral Palsy: A Matched Comparison of 90-Day Adverse Events and 5-Year Implant Survival

BackgroundPeople with cerebral palsy (CP) may be considered for total hip arthroplasty (THA). However, short- and long-term outcomes after THA in this population remain poorly characterized.MethodsData from patients undergoing THA were abstracted from the 2010-2018 PearlDiver Mariner administrative database. Those with CP were matched to those without CP based on demographic and comorbid factors (1:4 matching). Ninety-day incidence of postoperative complications and hospital readmission was identified and compared. Five-year implant survival (based on need for revision) was also assessed and compared.Perioperative adverse events were then compared using multivariate logistic regression to adjust for any potential residual differences in demographic and comorbid factors after matching. Implant survival over time was compared with Kaplan-Meier plots with a log-rank test. Significance was set at P < .05 for all comparisons.ResultsIn total, 864 patients with CP were matched to 3448 patients without CP. After adjusting for differences in demographics and comorbidities, multivariate analyses demonstrated patients with CP had higher odds of urinary tract infection (odds ratio [OR] = 2.42, P = .007), pneumonia (OR = 3.77, P = .001), and periprosthetic fracture (OR = 2.55, P = .001). Rates of the other studied adverse events, including readmissions, were not significantly different between groups.At five years, 94.2% of the CP cohort and 95.2% of the non-CP cohort THAs remained unrevised (no difference by log rank, P = .195).ConclusionCompared with patients without CP, patients with CP undergoing THA were found to have higher odds of perioperative urinary tract infection, pneumonia, and periprosthetic fracture but not other perioperative complications or difference in five-year implant survival.