How the Shift in Arthroplasty Surgery Location Impacts the Relationship of Private Surgeons,Hospitals, and Ambulatory Surgery Centers

The recent removal of total hip and knee arthroplasty from the Medicare inpatient-only list, COVID-19 pandemic, decreasing reimbursements, and bundled payment programs have all had tremendous impact on the practice of arthroplasty. Surgeons and practices must adapt to these challenges to achieve the ideal triad of quality patient care, low cost to payors, and sustainable financial margins for stakeholders. Here, we review institutional data and present our experience with the changing arthroplasty practice landscape. With the principle of demand matching, arthroplasty surgeons and practices can risk-stratify and shuttle patients in the appropriate operative and rehabilitation setting to optimize quality and efficiency.     

Systematic review of single stage revision for prosthetic joint infection

While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.     

Demand Matching Total Joint Replacement Patients Results in Reduction of Post-Discharge Costs

BackgroundThe shift from fee-for-service to value-based care has focused payers and providers on resource utilization. One important component of value-based care is to reduce the use of post-discharge (PD) services in a clinically appropriate manner following total joint arthroplasty (TJA). Demand matching in healthcare is the process of tailoring appropriate medical care to a patient with respect to that patient’s specific medical needs and social determinants. Outcomes following the implementation of a demand-matching algorithm for coordinating PD services after TJA were analyzed in this study.MethodsPayment data from all Medicare patients undergoing primary unilateral TJA between July 2014 and December 2018 from a single orthopedic practice were included. These payments were separated into acute and PD care. The initial acute and PD costs were compared to costs at the end of the 4-year study period using multiple linear regression and chi-square.ResultsA total of 9,638 patients (4,212 total hip arthroplasties and 5,430 total knee arthroplasties) were included. Acute costs of TJA were stable averaging $13,712.00. PD costs fell steadily from a baseline average of $7,319.00 in July 2014 to $4,678.00 in December 2018 (P < .001), representing a 36.1% decline. Discharge to home increased steadily from 45.8% to 79.9% during the same interval (P < .001.)ConclusionOur results demonstrate a statistically significant reduction in PD costs over a 4-year period using a demand-matching strategy to align with the Centers for Medicare and Medicaid Services mandate for value-based care. Based on these data, we conclude that thoughtful preoperative assessment of patient factors such as social determinants and medical comorbidities could allow for cost reduction through better utilization of PD services.     

Adding Value to Total Joint Arthroplasty Care in an Academic Environment: The Utah Experience

Background

Adding value in a university-based academic health care system provides unique challenges when compared to other health care delivery models. Herein, we describe our experience in adding value to joint arthroplasty care at the University of Utah, where the concept of value-based health care reform has become an embraced and driving force.

Outcomes Over 90-Day Episodes of Care in Medicare Fee-for-Service Beneficiaries Receiving Joint Arthroplasty

Background

In an effort to improve quality and reduce costs, payments are being increasingly tied to value through alternative payment models, such as episode-based payments. The objective of this study was to better understand the pattern and variation in outcomes among Medicare beneficiaries receiving lower extremity joint arthroplasty over 90-day episodes of care.

Thirty-Day Readmission Following Total Hip and Knee Arthroplasty – A Preliminary Single Institution Predictive Model

We sought to identify demographic or care process variables associated with increased 30-day readmission within the total hip and knee arthroplasty patient population. Using this information, we generated a model to predict 30-day readmission risk following total hip and knee arthroplasty procedures. Longer index length of stay, discharge disposition to a nursing facility, blood transfusion, general anesthesia, anemia, anticoagulation status prior to index admission, and Charlson Comorbidity Index greater than 2 were identified as independent risk factors for readmission. Care process factors during the hospital stay appear to have a large predictive value for 30-day readmission. Specific comorbidities and patient demographic factors showed less significance. The predictive nomogram constructed for primary total joint readmission had a bootstrap-corrected concordance statistic of 0.76.     

The High Value Healthcare Collaborative: Observational Analyses of Care Episodes for Hip and Knee Arthroplasty Surgery

Background

Broader use of value-based reimbursement models will require providers to transparently demonstrate health care value. We sought to determine and report cost and quality data for episodes of hip and knee arthroplasty surgery among 13 members of the High Value Healthcare Collaborative (HVHC), a consortium of health care systems interested in improving health care value.

Medicaid and state-based programs

Medicaid has played a substantial role in providing health insurance coverage and benefits for many low-income families. However, rising costs pose a significant challenge to beneficiaries, providers, and state and federal governments. The Affordable Care Act, enacted in 2010, served to expand coverage, lower costs, and improve quality of care. As the landscape of healthcare continues to evolve, it is necessary to assess the status of Medicaid and discuss developments at the state and federal level. Our report examines the opportunities afforded by Medicaid expansion, the progress of healthcare reform in total joint arthroplasty, and our experience with the Affordable Care Act.     

The 5 Clinical Pillars of Value for Total Joint Arthroplasty in a Bundled Payment Paradigm

Background

Our large, urban, tertiary, university-based institution reflects on its 4-year experience with Bundled Payments for Care Improvement. We will describe the importance of 5 clinical pillars that have contributed to the early success of our bundled payment initiative. We are convinced that value-based care delivered through bundled payment initiatives is the best method to optimize patient outcomes while rewarding surgeons and hospitals for adapting to the evolving healthcare reforms.

Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission

BackgroundExtended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments.MethodsWe performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012–2013) and after (2016–2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests.ResultsOf the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to –16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use.ConclusionDespite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.     

The Association Between Hospital Length of Stay and 90-Day Readmission Risk Within a Total Joint Arthroplasty Bundled Payment Initiative

Background

To curb the unsustainable rise in health care expenses, health care payers are developing programs to incentivize hospitals and physicians to improve the value of care delivered to patients. Payers are utilizing various metrics, such as length of stay (LOS) and unplanned readmissions, to track progression of quality metrics. Relevant to orthopedic surgeons, the Centers for Medicare and Medicaid Services announced in 2015 the Comprehensive Care for Joint Replacement Payment Model—a program aimed at improving the quality of health care delivered to patients by shifting more of the financial risk of patient care onto providers.

Maximizing Physician-Hospital Alignment: Lessons Learned From Effective Models of Joint Arthroplasty Care

Background

With recent healthcare reform efforts focusing on rewarding value instead of volume, it has become important for orthopedic surgeons to partner and align with their hospitals. We report our experience in aligning clinical and financial incentives with 6 health systems in our geographic area.

The two-stage standard: Res ipsa loquitur

Periprosthetic joint infection is a morbid and costly complication of total knee arthroplasty. Treatment options vary depending on chronicity of the infection, causative organism, and host factors. Some authors advocate single-stage exchange arthroplasty to decrease patient morbidity and healthcare utilization costs. Due to its proven efficacy for infection eradication and soft tissue healing, however, two-stage exchange arthroplasty remains the gold standard for treatment of periprosthetic joint infection after total knee arthroplasty. In this review, we present the technique of two-stage exchange arthroplasty and evidence supporting its use.     

Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project—Phase II Outcomes

BackgroundOur institution previously initiated a perioperative surgical home initiative to improve quality and efficiency across the hospital arc of care of primary total knee arthroplasty and total hip arthroplasty patients. Phase II of this project aimed to (1) expand the perioperative surgical home to include revision total hip arthroplasties and total knee arthroplasties, hip preservation procedures, and reconstructions after oncologic resections; (2) expand the project to include the preoperative phase; and (3) further refine the perioperative surgical home goals accomplished in phase I.MethodsPhase II of the Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies project ran from July 2018 to July 2019. The evaluated arc of care spanned from the preoperative surgical consult visit through 90 days postoperative in the expanded population described above.ResultsMean length of stay decreased from 2.2 days to 2.0 days (P < .001), 90-day readmission decreased from 3.0% to 1.6% (P < .001), and Press-Ganey scores increased from 77.1 to 79.2 (97th percentile). Mean and maximum pain scores and opioid consumption remained unchanged (lowest P = .31). Annual surgical volume increased by 10%. Composite changes in surgical volume and cost reductions equaled $5 million.ConclusionApplication of previously successful health systems engineering tools and methods in phase I of Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies enabled additional evolution of an orthopedic perioperative surgical home to encompass more diverse and complex patient populations while increasing system-wide quality, safety, and financial outcomes. Improved process and outcomes metrics reflected increased efficiency across the episode of care without untoward effects.Level of EvidenceIII Therapeutic.     

Increasing Perioperative Communication With Automated Mobile Phone Messaging in Total Joint Arthroplasty

Background

Automated mobile phone messaging has not been reported in total joint arthroplasty (TJA). Our purpose was to compare Press Ganey (PG) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores between TJA patients who did and did not receive perioperative automated mobile phone messages.

Implementation of a Total Hip Arthroplasty Care Pathway at a High-Volume Health System: Effect on Length of Stay,Discharge Disposition,and 90-Day Complications

Background

Standardized care pathways are evidence-based algorithms for optimizing an episode of care. Despite the theoretical promise of care pathways, there is an inconsistent literature demonstrating improvements in patient care. The authors hypothesized that implementing a care pathway, across 11 hospitals, would decrease hospital length of stay (LOS), decrease postoperative complications at 90 days, and increase discharges to home.

Joint replacement in the geriatric orthopaedic patient

Total hip arthroplasty and total knee arthroplasty are two of the most commonly performed orthopaedic procedures. With the tremendous success in relieving pain and restoring function, the indications for total joint arthroplasties (TJA) have been extended to the elderly patient. As the elderly portion of our population increases in both absolute and percentage terms we can expect an increased demand for TJA. This paper reviews the particularities of performing TJA on the elderly patient. The goal of this paper is to provide the orthopaedic surgeon with a framework within which to care for the elderly TJA patient. We discuss the nonoperative management of lower extremity arthritis. We review the orthopaedic preoperative assessment of the elderly patient and the role of medical internists and subspecialists to determine surgical risk and to identify and prevent potential postoperative complications. Specific surgical considerations are addressed for performing TJA on the elderly patient and techniques for both a hybrid total hip arthroplasty and a cemented total knee arthroplasty are discussed. Postoperative management considerations are then addressed.     

Surgeons’ Preoperative Work Burden Has Increased Before Total Joint Arthroplasty: A Survey of AAHKS Members

BackgroundImplementation of rapid recovery protocols and value-based programs in total joint arthroplasty (TJA) has required changes in preoperative management, such as optimization, education, and coordination. This study aimed to quantify the work burden associated with preoperative TJA care.MethodsTwo web-based surveys were distributed to surgeon members of the American Association of Hip and Knee Surgeons. The first questionnaire (265 respondents) consisted of questions related to preoperative patient care in TJA and the associated work burden by orthopedic surgeons and their financially dependent health care providers. The second survey (561 respondents) consisted of questions related to relative change in preoperative patient care work burden since 2013.ResultsGreater than 98% of survey respondents reported providing some level of preoperative medical optimization to their patients. The mean amount of reported time spent by the surgeon and/or a qualified health care provider in preoperative activities not included in work captured in current procedural terminology or hospital billing codes was 153 minutes. The mean amount of reported time spent by ancillary clinical staff in preoperative activities was 177 minutes. Most surgeons reported an increase in work burden for total knee (86%) and total hip (87%) arthroplasty since 2013, with a large portion reporting a 20% or greater increase in work (knee 66%, hip 64%).ConclusionTo provide quality arthroplasty care with marked reductions in complication rates, lengths of stay, and readmissions, members of the American Association of Hip and Knee Surgeons report a substantial preoperative work burden that is not included in current coding metrics. Policy makers should account for this time in coding models to continue to promote pathway improvements.     

Outpatient,Home-Based Physical Therapy Promotes Decreased Length of Stay and Post-Acute Resource Utilization After Total Joint Arthroplasty

BackgroundPatients and healthcare systems are increasingly focused on evaluating interventions that increase the value of care delivered. Our objective of this study is to evaluate early post-operative outcomes among those patients who underwent total joint arthroplasty with and without the participation in our piloted Outpatient Physical Therapy Home Visits (OPTHV) program.MethodsA retrospective analysis of patients undergoing total hip arthroplasty and total knee arthroplasty at a single institution from July 2016 to September 2017 was performed. Matched cohorts were compared according to OPTHV enrollment status.ResultsIn total, 1729 patients were included in this study. Two hundred ninety-three patients were enrolled in OPTHV, while 1436 patients received institutional standard care. Patients were matched by gender (56.7% vs 57.7% female, P = .751), age (67.75 vs 66.95 years, P = .167), body mass index (30.18 vs 30.12 kg/m², P = .859), and average American Society of Anesthesiologists score (2.31 vs 2.36, P = .131). OPTHV patients had a shorter length of stay (1.39 vs 1.64 days, P < .001) and were more likely to discharge to home (89.8% vs 74.7%, P < .001). Ninety-day re-admissions (2.7% vs 2.6%, P = .880) and emergency room visits (4.1% vs 4.3%, P = .864) were equivalent.ConclusionOPTHV is a novel program that facilitates discharge home and decreased length of stay after total joint arthroplasty without increasing re-admissions or emergency room visits. Utilization of OPTHV may contribute toward reducing the episode of care costs by reducing utilization of skilled nursing facility and home health services. Further prospective studies are needed to evaluate the effect of OPTHV on the total cost of care and functional outcomes.     

Failure of interpositional membrane to prevent recurrent arthrofibrosis

Silicone has been used in numerous health care roles, from catheters to finger joint arthroplasties, with proven success. Its use as an interpositional membrane for the prevention of adhesions has been attempted in various anatomic sites with unpredictable results. We present a case report of a patient with recurrent arthrofibrosis requiring multiple operative procedures including manipulations under anesthesia, arthroscopies, and unicompartmental and eventual total knee replacement. After developing stiffness after total knee arthroplasty, the patient received placement of a silicone interpositional membrane with the goal of minimizing scar formation. Arthrofibrosis recurred, and only eventual removal of the membrane and correction of the underlying overstuffed patellofemoral compartment has allowed for maintained functional improvement in motion after 3 years.