Increased Medical Complications,Revisions, In-Hospital Lengths of Stay,and Cost in Patients With Hypogonadism Undergoing Primary Total Knee Arthroplasty

BackgroundResearch regarding the impact of hypogonadism following primary total knee arthroplasty (TKA) is limited. Therefore, the purpose of this study is to investigate whether patients with hypogonadism undergoing primary TKA are at increased odds of (1) medical complications, (2) revisions, (3) in-hospital lengths of stay (LOSs), and (4) cost of care.MethodsA Humana patient population consisting of 8 million lives was retrospectively analyzed from 2007 to 2017 using International Classification of Disease, 9th Revision codes. Patients were filtered by male gender and patients with hypogonadism were matched to controls in a 1:4 ratio according to age and medical comorbidities. The query yielded 8393 patients with (n = 1681) and without (6712) hypogonadism undergoing primary TKA. Primary outcomes analyzed included medical complications, revision rates, in-hospital LOS, and cost of care. Logistic regression analysis was used to calculate odds ratios (OR) of 90-day medical complications and 2-year revisions. Welch’s t-test was used to test for significance in LOS and cost of care between cohorts. A P-value less than .05 was considered statistically significant.ResultsHypogonadal patients undergoing primary TKA were found to have increased incidence and odds (9.45% vs 4.67%; OR 2.12, P < .0001) of developing 90-day medical complications. Hypogonadal patients undergoing primary TKA were found to have a greater incidence and odds (3.99% vs 2.80%; OR 1.89, P < .0001) of 2-year revisions. Hypogonadal patients had a 6.11% longer LOS (3.47 vs 3.27 days, P = .02) compared to controls, and incurred greater 90-day costs ($15,564.31 vs $14,856.69, P = .018) compared to controls.ConclusionThis analysis of over 1600 patients demonstrates that patients with hypogonadism undergoing primary TKA have greater odds of postoperative medical complications, revisions, increased LOS, and cost of care.     

Perioperative Systemic Dexamethasone Reduces Length of Stay in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundThe objective of this review is to examine the effect of perioperative systemic corticosteroids at varying doses and timings on early postoperative recovery outcomes following unilateral total knee and total hip arthroplasty. The primary outcome was length of stay (LOS).MethodsA systematic review and meta-analysis of randomized controlled trials was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to June 1, 2020. Studies comparing the outcome of adult patients receiving a systemic steroid to patients who did not receive steroids were included.ResultsSeventeen studies were included, incorporating 1957 patients. Perioperative corticosteroids reduced hospital LOS (mean difference [MD] = ?0.39 days, 95% confidence interval [CI] ?0.61 to ?0.18). A subsequent dose of corticosteroid at 24 hours further reduced LOS (MD = ?0.33, 95% CI ?0.55 to ?0.11). Corticosteroids resulted in reduced levels of pain on postoperative day (POD) 0 (MD = ?1.99, 95% CI ?3.30 to ?0.69), POD1 (MD = ?1.47, 95% CI ?2.15 to ?0.79), and POD2. Higher doses were more effective in reducing pain with activity on POD0 (P = .006) and 1 (P = .023). Steroids reduced the incidence of PONV on POD1 (log odds ratio [OR] = ?1.05, 95% CI ?1.26 to ?0.84) and POD2, with greater effect at higher doses (P = .046). Corticosteroids did not increase the incidence of infection (P = 1.000), venous thromboembolism (P = 1.000), or gastrointestinal hemorrhage (P = 1.000) but were associated with an increase in blood glucose (MD = 5.30 mg/dL, 95% CI 2.69-7.90).ConclusionPerioperative corticosteroids are safe, facilitate earlier discharge, and improve patient recovery following unilateral total knee arthroplasty and total hip arthroplasty. Higher doses (15-20 mg of dexamethasone) are associated with further reductions in dynamic pain and PONV, and repeat dosing may further reduce LOS.     

Does the Timing of the Second Surgery of a Staged Bilateral Total Joint Arthroplasty Affect the Rate of Hospital Adverse Events and Perioperative Outcomes?

BackgroundThe optimal timing of the second surgery in primary staged bilateral total hip/knee arthroplasty remains uncertain. Perioperative hospital adverse events represent a significant issue, even “minor events” lead to substantial costs in workup tests, interconsultations, and/or increased hospital length-of-stay (LOS). Therefore, we sought to ascertain whether the timing of the second arthroplasty affects perioperative outcomes and/or rates of adverse events.MethodsWe retrospectively reviewed a consecutive series of 670 primary staged bilateral total hip/knee arthroplasty performed by 2 surgeons (2010-2016) at a single institution. The days between both arthroplasties were calculated for each pair of hips or knees. We evaluated demographics and LOS, discharge disposition, adverse events (ie, nausea, pulmonary embolism), and transfusion rates. The second arthroplasties (n = 335) were set apart in 2 groups based on the time they were done with respect to their corresponding contralateral first arthroplasty using 3 different thresholds: (1) ≤90 vs >90 days, (2) ≤180 vs >180 days, and (3) ≤365 vs >365 days.ResultsNo significant differences in outcome comparisons were observed using either 90 or 180 days thresholds. However, using the 365 days thresholds, the mean LOS (2.21 vs 1.92 days, P = .015), adverse event (26% vs 15.3%, P = .021), total transfusion (7.4% vs 1.5%, P = .020), and allogeneic transfusion (6.9% vs 1.5%, P = .033) rates were significantly higher in second arthroplasties performed at or less than 1 year apart from the first, respectively.ConclusionStaging the second arthroplasty more than a year apart from the first one seems to offer better LOS and rates of hospital adverse events, transfusions. However, unless patients are willing to wait a year between surgeries, our data also suggest no increased risk in regards to adverse events when proceeding before or after 90/180 days.Level of EvidenceLevel III.     

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.     

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.     

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.     

Effect of Tourniquet Use on Patient Outcomes After Cementless Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundTourniquet use is common in total knee arthroplasty (TKA), but debate exists regarding its use and effect on patient outcomes. The study purpose was to compare the effect of short tourniquet (ST) time vs long tourniquet (LT) time on pain, opioid consumption, and patient outcomes.MethodsPatients were prospectively randomized to an ST time of 10 min vs LT time. A total of 100 consecutive patients undergoing primary cementless robotic-assisted TKA underwent randomization, with 5 patients unable to complete follow-up, leaving 49 in the ST group and 46 in the LT cohort. Visual analog scale pain scores, morphine equivalent, serum creatine kinase, distance walked, range of motion, length of stay (LOS), surgical time, hemoglobin (Hgb), and Knee Society Scores (KSS) were prospectively collected.ResultsVisual analog scale pain was statistically equivalent at 24, 48, and 72 hours and at 2 and 6 weeks postoperatively. Morphine equivalent consumption was 36 vs 44 (P = .03), 48 vs 50 (P = .72), 31 vs 28 (P = .57), and 4.7 vs 5.5 (P = .75) in the LT vs ST cohorts at 24 hours, 48 hours, 2weeks, and 6weeks postoperatively. Change in Hgb postoperative day 1 was 2.7 in both groups (P = .975). Postoperative day 1 creatine kinase-MB was 3.7 and 3.0 (P = .30) in LT and ST cohorts. Six-week postoperative KSS Knee and Function scores were 82.4 and 70.5 in LT group vs 80.8 and 72.3 in ST group (P = .61 and P = .63). Postoperative range of motion, LOS, and surgical time were equivalent.ConclusionThis study demonstrates no significant advantage of ST use in primary TKA with respect to opioid consumption, patient-reported pain, KSS scores, LOS, or postoperative Hgb level.     

Are Patients Being Appropriately Selected for Same-Day Discharge Total Knee Arthroplasty?

BackgroundDecreased cost associated with same-day discharge (SDD) total knee arthroplasty (TKA) has led to an increased interest in this topic. The purpose of this study is to investigate whether there is a population of TKA patients in which SDD has similar rates of 30-day complications compared to patients discharged on postoperative day 1 or 2.MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, 6,327 TKA patients who had a SDD (length of stay [LOS] = 0) were matched to TKA patients who had an LOS of 1 or 2 days. All SDD patients were successfully matched 1:1 using the morbidity probability variable (a composite variable of demographics, comorbidities, and laboratory values). Patients were divided into quartiles based on their morbidity probability. Bivariate logistic regressions were then used to compare any complication and major complication rates in the SDD quartiles to the corresponding quartiles with an LOS of 1 or 2 days.ResultsWhen comparing the 1st quartiles (healthiest), there was no difference between the cohorts in any complication (odds ratio [OR] = 0.960, 95% CI 0.552-1.670, P = .866) and major complications (OR = 0.999, 95% CI = 0.448-2.231, P = .999). The same was observed in quartile 2 (any complications: OR = 1.161, 95% CI = 0.720-1.874, P = .540). Comparing the third quartiles, there was an increase in all complications with SDD (OR = 1.784, 95% CI = 1.125-2.829, P = .014), but no difference in major complications (OR = 1.635, 95% CI = 0.874-3.061, P = .124). Comparing the fourth quartiles (least healthy), there was an increase in all complications (OR = 1.384, 95% CI = 1.013-1.892, P = .042) and major complications (OR = 1.711, 95% CI = 1.048-2.793, P = .032) with SDD.ConclusionThe unhealthiest 50% of patients in this study who underwent SDD TKA were at an increased risk of having any complication, calling into question the current state of patient selection for SDD TKA.Level of EvidenceIII.     

Optimizing Spinal Anesthesia in Same-Day Discharge Knee Arthroplasty Patients: Mepivacaine Versus Ropivacaine

BackgroundShort-acting spinal anesthetics are playing an increasing role in same-day discharge total joint arthroplasty though their direct comparison remains to be studied. Therefore, this study aims to compare two formulations of spinal anesthesia regarding time to discharge following knee arthroplasty surgery.MethodsA retrospective study was performed on 207 patients who underwent unicompartmental knee arthroplasty (UKA, n = 172) and total knee arthroplasty (TKA, n = 35) from May 2018 to December 2020 at a single institution and were discharged the same day. Two formulations of the spinal anesthetic were routinely administered in this population: 1) mepivacaine 1.5% 3-4 mL (n = 184) and 2) ropivacaine 0.5% 2.3-2.7 mL (n = 23). Discharge times were subsequently compared between mepivacaine and ropivacaine spinal anesthesia for each surgical procedure and between surgical procedures.ResultsThere was no significant difference in discharge times between patients receiving mepivacaine versus ropivacaine for UKA (202 minutes [range = 54-449] versus 218 minutes [range = 175-385], P = .45) or TKA (193 minutes [range = 68-384] versus 196 minutes [range = 68-412], P = .93). Similarly, no difference was found in discharge times between UKA and TKA patients receiving mepivacaine (P = .68) or ropivacaine (P = .51).ConclusionThere was no significant difference in discharge times between anesthetic agents among knee surgery patients. Therefore, either agent may be recommended for same-day discharge.     

Staged Versus Simultaneous Bilateral Knee Arthroplasty: Does Minimal Cost Difference Justify Risks?

BackgroundSimultaneous bilateral total knee arthroplasty (BTKA) is associated with a higher risk but can be perceived to afford faster improvement and mitigated costs versus staged BTKA. We aimed to explore (1) health care utilization, (2) surgical supply costs of simultaneous BTKA; and (3) 1-year improvement in patient-reported pain, function, and quality of life (QOL) versus staged BTKA.MethodsA prospective cohort of 198 simultaneous and 625 staged BTKAs was obtained (2016-2020). Simultaneous BTKA cohort was propensity score-matched (1:2) to a similar group of staged patients (simultaneous = 198 versus staged = 396). Outcomes included length of stay, discharge disposition, 90-day readmission, 1-year reoperation, surgical episode supply cost, Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain, KOOS-Physical Function Short Form, and KOOS-QOL. Rates of attaining minimal clinically important difference and Patient Acceptable Symptomatic State were calculated.ResultsCompared to both staged BTKA surgeries combined, simultaneous BTKA demonstrated shorter median net length of stay (2.00 [2.00, 3.00] days versus 2.00 [2.00, 4.00] days; P < .001) but higher rates of nonhome discharge (n = 56 [28.3%] versus n = 32 [4.04%]; P < .001), 90-day readmission (n = 20 [10.1%] versus n = 48 [6.06%]; P = .047) and similar reoperation rates (P = .44). Simultaneous BTKA afforded slight reduction in net surgical cost compared to that of both staged BTKAs combined ($643; P = .028). There was no significant difference in 1-year improvement and minimal clinically important difference attainment rates with simultaneous versus staged BTKA for KOOS-pain (P = .137 and P = .99), KOOS-QOL (P = .095 and P = .81), or KOOS-Physical Function Short Form (P = .75 and P = .49, respectively) or Patient Acceptable Symptomatic State (P = .12).ConclusionStaged BTKA is associated with similar 1-year pain, function, and QOL at a better safety profile and minimal surgical supply cost increase compared to simultaneous BTKA.     

Osteoarthritis and Osteonecrosis in Total Hip Arthroplasty: 90-Day Postoperative Costs and Outcomes

BackgroundTwo common diagnoses for patients undergoing total hip arthroplasty (THA) are osteoarthritis (OA) and osteonecrosis (ON), pathologically different diseases that affect postoperative complication rates. The underlying pathology of ON may predispose patients to a higher rate of certain complications. Previous research has linked ON with higher mortality and revisions, but a comparison of costs and complication rates may help elucidate further risks. This study reports 90-day costs, lengths of stay (LOS), readmission rates, and complication rates between patients undergoing THA for OA and ON.MethodsThe Nationwide Readmissions Database was retrospectively reviewed for primary THAs, with 90-day readmissions assessed from the index procedure. Patients diagnosed with OA (n = 1,577,991) and ON (n = 55,034) were identified. Costs, LOS, and any readmission within 90 days for complications were recorded and analyzed with the chi-square and t-tests.ResultsPatients with ON had higher 90-day costs ($20,110.80 vs. 22,462.79, P < .01) and longer average LOS (3.48 vs. 4.49 days, P < .01). Readmission rates within 90 days of index THA were significantly higher among patients with ON (7.7% vs. 13.1%, P < .01). Patients with OA had a lower incidence of 90-day overall complications (4.1 vs. 6.4%, P < .01).ConclusionsPatients undergoing THA for ON incur higher readmission-related costs and complication rates. Understanding the predisposing factors for increased complications in ON may improve patient outcomes.     

Do Patient Engagement Platforms in Total Joint Arthroplasty Improve Patient-Reported Outcomes?

BackgroundWeb-based patient engagement portals are increasing in popularity after total hip and knee arthroplasty (THA and TKA). The literature is mixed regarding patient utilization of these modalities and potential clinical benefit. We sought to determine which demographic factors are associated with increased platform participation and to quantify the impact of a web-based patient portal on patient-reported outcome measures (PROMs).MethodsWe performed a retrospective analysis of consecutive primary THA (n = 554) and TKA (n = 485) at a single academic institution with minimum follow-up of 12 months. Patients were divided into those who opted-in and those who opted-out of portal use. Global health and joint-specific PROMs were collected preoperatively and postoperatively. Linear mixed effects modeling, bivariate analysis, and logistic regression were utilized.ResultsOf the 1039 included patients, 60.6% (336) THA and 62.7% (304) TKA patients enrolled in the portal. Those who opted-in were younger (P < .001, P < .003), had higher body mass index (P = .024, P = .011), and had a higher household income (P < .001, P < .001) in THA and TKA cohorts, respectively. Portal participation in the TKA but not the THA cohort was associated with significant improvement in physical function (P = .017) and joint-specific function (P = .045). For THA patients who opted-in, increased portal logins were associated with more rapid improvement and higher functional scores (P = .013).ConclusionThere is an inherent difference between patients who opt-in to and those who opt-out of web-based portals. Added resources and support provided by portals may translate to improved PROMs for TKA patients but not THA patients.     

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.     

One-Stage Sequential Bilateral Total Knee Arthroplasty: An Effective Treatment for Advanced Bilateral Knee Osteoarthritis Providing High Patient Satisfaction

BackgroundThe mortality and risks of bilateral total knee arthroplasty (BTKA) have been reported to be far greater than in unilateral total knee arthroplasty (UTKA). This study aimed to determine whether this remains the case using contemporary anesthetic and surgical techniques for one-stage single anesthetic sequential BTKA.MethodsTwo cohorts of 394 patients were created by propensity matching for gender, age, body mass index, American Society of Anesthesiologists grade, and Veterans Rand-12 health survey scores. Primary outcome was morbidity and mortality, with satisfaction measures using patient-reported outcome measures.ResultsThe mortality rate was low with one case after BTKA. Major complications were also low; however, a pulmonary embolism rate of 2% in BTKA patients was significantly higher than 0.3% after UTKA (P < .05), and associated with an American Society of Anesthesiologists grade ≥3. The rate of minor complications between the 2 cohorts was comparable (P = .95). Blood transfusions were uncommon and not significantly different between cohorts (2.5% vs 1.3%, P = .3). BTKA patients stayed in hospital a mean 1.3 days longer with greater rehabilitation requirements. At final follow-up, patient satisfaction was high with all patient-reported outcome measures significantly improved and comparable between cohorts.ConclusionBTKA is safe and effective in the majority of patients. Transfusion rates were far lower than historically reported and major complications were rare after both UTKA and BTKA. A significant increase in the rate of pulmonary embolism after BTKA was observed, especially in high risk patients. At minimum 1-year postoperatively, cohorts had the same significant clinical improvement and high level of satisfaction.     

A Comparison of Neuraxial and General Anesthesia for Thirty-Day Postoperative Outcomes in United States Veterans Undergoing Total Knee Arthroplasty

BackgroundThe aim of this study is to investigate which anesthetic technique is superior on 30-day outcomes after primary total knee arthroplasty (TKA) in United States veteran patients. To our knowledge, this is the first account from the Veterans Health Administration comparing the effects of different anesthesia modalities in patients undergoing TKA.MethodsThe Veterans Affairs Surgical Quality Improvement Program database was utilized to analyze patients undergoing primary TKA during the period of 2008-2015. Subjects were divided into 2 cohorts based on the method of surgical anesthesia used: general anesthesia or neuraxial anesthesia. Propensity score matching was utilized to avoid possible selection bias between the 2 cohorts when assessing patient demographics and comorbidities. The 2 groups were analyzed for 30-day postoperative complications, using multivariable logistic regression techniques to evaluate independent associations between anesthetic method and postoperative outcomes.ResultsAll Veterans Affairs patients undergoing primary TKA under general anesthesia (n = 32,363) and neuraxial anesthesia (n = 14,395) within the study period were included in this study. Following propensity score matching, multivariable analysis revealed significantly lower risks of cardiovascular (adjusted odds ratio [AOR] 0.74, 95% confidence interval [CI] 0.6-0.88, P < .001), respiratory (AOR 0.75, 95% CI 0.57-0.97, P = .03), and renal complications (AOR 0.62, 95% CI 0.4-0.9, P = .01) in patients receiving neuraxial anesthesia compared to those receiving general anesthesia. Neuraxial anesthesia was also associated with reduced hospital stay and lower odds of prolonged hospitalization (AOR 0.85, 95% CI 0.8-0.9, P < .001).ConclusionVeteran patients undergoing TKA under neuraxial anesthesia had reduced postoperative complications and decreased hospitalization stay compared to patients undergoing general anesthesia.     

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.     

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.     

The Affordable Care Act and Global Budget Revenue: The Impact on Total Hip Arthroplasties

BackgroundMaryland possesses a unique, population-based alternative payment model named Global Budget Revenue (GBR). This study evaluated the effects of GBR on demographics and outcomes for patients who underwent primary total hip arthroplasty (THA) by comparing Maryland to the United States (U.S.).MethodsWe identified primary THA patients in the Maryland State Inpatient Database (n = 35,925) and the National Inpatient Sample (n = 2,155,703) between 2011 and 2016 utilizing International Classification of Diseases 9 and 10 diagnosis codes. Qualitative analysis was used to report trends. Multiple regressions were used for difference-in-difference (DID) analyses to compare Maryland to the U.S. between pre-GBR (2011-2013) and post-GBR (2014-2016) periods.ResultsAfter GBR implementation, there were proportionally more patients who were obese (Maryland: +5.1% vs U.S.: +3.0%), used Medicare (+1.6% vs +0.7%), used Medicaid (+2.4% vs +1.3%) while less used private insurance (−4.2% vs −1.8%) (all P < .001). There were proportionally less home health care patients in Maryland, but more in the U.S. (−3.5% vs +1.6%; both P < .001). The mean costs decreased for both cohorts (−$1780.80 vs −$209.40; both P < .001). The DID found Maryland saw more Medicaid and less private insurance patients under GBR (both P ≤ .001). Maryland saw more obese patients than would be expected (P = .001). The DID also found decreased costs for patients under GBR (P < .001 for both).ConclusionMaryland has benefitted from GBR with decreased cost and an increase in Medicaid patients. Maryland may provide a viable model for future healthcare policies that incorporate global budgets.     

Chronic Obstructive Pulmonary Disease Is Associated With Higher Rates of Venous Thromboemboli Following Primary Total Knee Arthroplasty

BackgroundThere is discordance in the literature regarding the presence of chronic obstructive pulmonary disease (COPD) and the development of venous thromboemboli (VTEs). Therefore, the purpose of this study is to determine whether COPD patients undergoing primary total knee arthroplasty (TKA) have higher rates of (1) in-hospital lengths of stay (LOS); (2) readmissions; (3) VTEs; and (4) costs of care.MethodsCOPD patients undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, gender, and medical comorbidities. Patients with a history of VTEs or hypercoagulable states were excluded. The query yielded 211,378 patients in the study (n = 35,230) and control (n = 176,148) cohorts. Outcomes analyzed included in-hospital LOS, readmission rates, VTEs, and costs of care. A P-value less than .01 was considered statistically significant.ResultsCOPD patients were found to have significantly longer in-hospital LOS (4 vs 3 days, P < .0001). Study group patients were also found to have significantly higher incidence and odds ratio (OR) of readmission rates (20.9% vs 16.3%; OR 1.36, P < .0001) and VTEs (1.75 vs .93; OR 1.18, P < .0001). Additionally, the study demonstrated that COPD patients incurred higher 90-day episode-of-care costs ($15,626.85 vs $14,471.29, P < .0001).ConclusionAfter adjusting for confounding variables, our study found an association between COPD and higher rates of developing VTEs following primary TKA. The study can be used by orthopedic surgeons to adequately counsel and educate these patients of the potential complications which may arise following their TKA.