Oncology Patients Are High Cost Outliers in Total Joint Replacement Bundled Payment Systems

BackgroundIn 2016, the Centers for Medicare and Medicaid Services began its first mandatory bundled payment program, the Comprehensive Care for Joint Replacement (CJR) model, which covers a 90-day episode of care. This study determined whether oncology patients enrolled in the CJR bundle incur higher hospital costs than patients with osteoarthritis (OA).MethodsA retrospective review of all patients enrolled in the CJR bundled payments system from April 1, 2016 to June 31, 2018 at a single academic medical center was conducted. To determine whether tumor patients had higher total episode costs, this group was compared to patients diagnosed with OA using a 2-tailed t-test. To adjust for moderators of total hospital costs, we used generalized linear regression with a log-link, including multiple variables abstracted from chart review.ResultsThree hundred fourteen patients met inclusion criteria (12 primary or metastatic tumors, 302 OA). Fifty-eight percent of tumor patients were over the target price vs 16% of OA patients. The mean tumor patient had $40,862 for total internal hospital costs compared to $16,356 in the OA group (P < .001). Length of stay was greater in the tumor group (6.75 vs 2.0 days, P < .001). A greater percentage of tumor patients were discharged to a skilled nursing facility (67% vs 27%, P = .006) with significantly higher skilled nursing facility episode costs ($18,852 vs $7731, P = .04). With adjustment for fracture status, tumor patients were 5.36 times more likely to exceed the CJR target price than OA patients (risk ratio 5.36, confidence interval 3.44-8.35, P < .001) and 50 times more likely to be outliers over the regional threshold than OA patients (risk ratio 50.33, confidence interval 16.33-155.19, P < .001).ConclusionOncology patients enrolled in the CJR bundled payment model incur significantly higher costs and have higher cost variability than patients with OA. We recommend that oncology patients be excluded from the CJR bundle.     

Evidence of Pent-Up Demand for Total Hip and Total Knee Arthroplasty at Age 65

Background

Despite efforts to curtail the economic burden of total joint arthroplasty (TJA), utilization of these successful procedures continues to increase. Previous studies have provided evidence for pent-up demand (delaying necessary medical care until financially feasible) in health care as insurance status changes. We sought to determine whether evidence exists for pent-up demand in the TJA population when patients become eligible for Medicare enrollment.

Preoperative Glycemic Control on Total Joint Arthroplasty Patient-Perceived Outcomes and Hospital Costs

Background

The purpose of this study was to determine the influence of preoperative glycemic control in diabetic patients undergoing a primary total hip or knee arthroplasty. We wanted to study patient-perceived outcomes in the medium term, the length of stay, hospital costs, and rate of short-term postoperative complications.

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.

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.

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

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

Long-Term Sustainability of a Quality Initiative Program on Transfusion Rates in Total Joint Arthroplasty: A Follow-Up Study

BackgroundThere are significant variations in transfusion rates among institutions performing total joint arthroplasty. We previously demonstrated that implementation of an educational program to increase awareness of the American Association of Blood Banks’ transfusion guidelines led to an immediate decrease in transfusion rates at our facilities. It remained unclear how this initiative would endure over time. We report the long-term success and sustainability of this quality program.MethodsWe reviewed the Michigan Arthroplasty Collaborative Quality Initiative data from 2012 through 2017 of all patients undergoing primary hip and knee arthroplasty at our institutions for preoperative and postoperative hemoglobin level, transfusion status, and number of units transfused and transfusions outside of protocol to identify changes surrounding our blood transfusion educational initiative. We calculated the transfusions prevented and cost implications over the course of the study.ResultsWe identified 6645 primary hip and knee arthroplasty patients. There was a significant decrease in transfusion rate and overall transfusions in each group when compared to pre-education values. Subgroup analysis of TKA and THA independently showed significant decreases in both transfusion rate and overall transfusions. Over the final 3 years of the study, only 2 patients were transfused outside of the American Association of Blood Banks protocol. We estimate prevention of 519 transfusions over the study period.ConclusionApplication of this quality initiative was an effective means of identifying opportunities for quality improvement. The program was easily initiated, had significant early impact, and has been shown to be sustainable.     

The Effect of Discharge Disposition on 30-Day Readmission Rates After Total Joint Arthroplasty

Previous studies have demonstrated no significant difference in overall functional outcomes of patients discharged to a sub acute setting versus home with health services after total joint arthroplasty. These findings coupled with pressure to reduce health care costs and the implementation of a prospective payment system under Medicare have supported the use of home rehabilitation services and the trend towards earlier discharge after hospitalization. While the overall functional outcome of patients discharged to various settings has been studied, there is a relative dearth of investigation comparing postoperative complications and readmission rates between various discharge dispositions. Our study demonstrated patients discharged home with health services had a significantly lower 30 day readmission rate compared to those discharged to inpatient rehab facilities. Patients discharged to rehab facilities have a higher incidence of comorbidity and this association could be responsible for their higher rate of readmission.     

Contemporary Total Hip and Total Knee Arthroplasty Results in Patients with Hemochromatosis

BackgroundHemochromatosis can result in metabolic bone pathology (due to excessive iron absorption) and degenerative joint disease, leading to total joint arthroplasties. The aim of this study is to analyze the survivorship, complications, radiographic results, and clinical outcomes of patients with hemochromatosis who received either a total hip arthroplasty (THA) or a total knee arthroplasty (TKA).MethodsWe identified 34 lower extremity arthroplasties in 29 patients with hemochromatosis performed between 2000 and 2016. There were 17 primary THAs in 15 patients and 17 primary TKAs in 14 patients. Mean age at arthroplasty was 63 years with 76% being male. The mean body mass index was 28 kg/m². Mean follow-up was 5 years.ResultsThe survivorship free from any revision for THAs was 94% at 10 years. One patient was revised for aseptic loosening of the femoral stem at 6 months. In THA patients, no infections, no other complications, and no radiographic evidence of aseptic loosening were identified. Harris Hip Scores improved from a mean of 55 preoperatively to 94 postoperatively (P < .001). The survivorship free from any revision for TKAs was 100% at 10 years. Two patients (12%) developed acquired idiopathic stiffness postoperatively; no infections were identified. There was no radiographic evidence of aseptic loosening in any TKA. Knee Society Scores improved from a mean of 61 preoperatively to 94 postoperatively (P < .001).ConclusionThis study found excellent survivorship, significant improvements in clinical outcomes, and a very low complication profile for both THA and TKA in patients with hemochromatosis.     

The Risk Assessment and Prediction Tool Is Less Accurate in Extended Length of Stay Patients Following Total Joint Arthroplasty

Background

Although preoperative risk assessment tools have been effective in predicting discharge disposition after total joint arthroplasty (TJA), studies reporting on discharge planning in extended length of stay (ELOS), >3 days, patients are lacking. The purpose of this study was to describe the predictive utility of the Risk Assessment and Prediction Tool (RAPT) for discharge disposition in ELOS patients.

Reference Pricing Reduces Total Knee Implant Costs

BackgroundReference pricing establishes a set price a hospital is willing to pay for total knee arthroplasty (TKA) components regardless of vendor. The hospital contracts with vendors that sell implants to the hospital at the hospital-dictated prices. Orthopedic surgeons are free to utilize any implant system that has met the reference price using their best clinical judgment. Our hypothesis is that vendors will meet the set price and selection of different vendors and technologies will not change.MethodsWe retrospectively analyzed the 12 months prior (May 2017-2018) and the most recent 12 months after (March 2019-2020) implementing reference pricing at our institution. We investigated differences in average prices for total implant and component costs. We evaluated cost of implants with respect to surgeon volume, assessed the rate of cementless TKAs used, and number of companies purchased from before and after reference pricing.ResultsIn total, 7148 TKAs were included in the study with 3790 arthroplasties before and 3358 after implementation of reference pricing. Overall implant costs decreased by 16.7% (P < .0001). All individual knee component costs decreased by at least 11% (P = .0003). No difference in prices were found among surgeons (P = .9758). Cementless knee use increased by 9% (P < .0001; odds ratio 1.94, 95% confidence interval = 1.69-2.24). No vendor business was lost.ConclusionThe strategy of reference pricing significantly reduced costs for TKA implants at our institution. The reduction in implant costs was regardless of surgeon volume. Newer technologies were utilized more often after reference pricing. This strategy represents a significant cost-savings approach for other hospitals.     

Ring Total Hip Replacement in Osteoarthrosis

A follow-up is given of the results of 40 arthroplasties with the non-cemented, vitalliuBQ-to-vitallium bearing Ring total hip prosthesis in 37 patients with osteoarthrosis. Operative indication was an intolerably painful and stiff joint. The surgery was performed by two specialists in orthopaedics. Point scores according to a modification of Merle d'Aubigne's classification showed excellent or at least good results in 52.5 per cent, and fair results in 27.5 per cent of the operations. One prosthesis was removed because of deep infection. The mortality rate was zero. in 20 per cent the total score was between 0 and 7, signifying little or no improvement. Loosening was the main problem even although it was in many cases well tolerated by the patients.     

The Role of Crosslinked Polyethylene in Reducing Aggregated Costs of Total Hip Arthroplasty in the United States

BackgroundWidespread adoption of crosslinked polyethylene for the acetabular articular surface for total hip arthroplasty has substantially reduced revision rates and dislocation rates. We aim to provide estimates of the resulting magnitude of the annual reduction in aggregated costs of total hip arthroplasty surgery in the United States.MethodsAfter we obtained, from the literature, the contrasting mid-term rates of revisions and dislocations of total hip arthroplasty using conventional polyethylene vs those using crosslinked polyethylene, specifically from only registry studies and prospective, randomized controlled studies, we multiplied these incidence figures by the cost estimates of these failures to generate approximations of the cost savings in the United States from the use of crosslinked polyethylene.ResultsThe estimates suggest that in the United States these savings might be one billion dollars per annual cohort over a 15-year duration.ConclusionThe use of crosslinked polyethylene has reduced substantially the overall costs of total hip arthroplasty surgery in the United States.     

An Overview of Telehealth in Total Joint Arthroplasty

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

Decreasing Total Joint Implant Costs and Physician Specific Cost Variation Through Negotiation

Reducing the cost of total joint implants can significantly reduce the cost of an episode of care without affecting the quality. In 2011 we began a program to decrease and standardize the pricing of total joint implants. In the first year of the intervention we preformed 1,090 and 1,022 unilateral total knee and total hip arthroplasties respectively. Based on our volume and pricing data, our institution saved over $2 million during the first year of this intervention. It is clear that our initiative to negotiate lower implant cost with our vendors has lead to a significant reduction in the cost of joint arthroplasties and a reduction in the variability in costs between physicians.     

Changes in Patient Satisfaction Following Total Joint Arthroplasty

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

Factors Associated With Early Return to Driving Following Total Joint Arthroplasty

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

Risk Factors and Costs Associated With Clostridium difficile Colitis in Patients With Prosthetic Joint Infection Undergoing Revision Total Hip Arthroplasty

Background

With the increased demand for primary total hip arthroplasty (THA) and corresponding rise in revision procedures, it is imperative to understand the factors contributing to the development of Clostridium difficile colitis. We aimed to provide a detailed analysis of: (1) the incidence of; (2) the demographics, lengths of stay, and total costs for; and (3) the risk factors and mortality associated with the development of C. difficile colitis after revision THA.

A Consultation Phone Service for Patients With Total Joint Arthroplasty May Reduce Unnecessary Emergency Department Visits

Background

Different measures for reducing costs after total joint arthroplasty (TJA) have gained attention lately. At our institution, a free-of-charge consultation phone service was initiated that targeted patients with TJA. This service aimed at reducing unnecessary emergency department (ED) visits and, thus, potentially improving the cost-effectiveness of TJAs. To our knowledge, a similar consultation service had not been described previously. We aimed at examining the rates and reasons for early postdischarge phone calls and evaluating the efficacy of this consultation service.