What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data

Background

Episode-of-care payments are defined as a single lump-sum payment for all services associated with a single medical event or surgery and are designed to incentivize efficiency and integration among providers and healthcare systems. A TKA is considered an exemplar for an episode-of-care payment model by many policymakers, but data describing variation payments between hospitals for TKA are extremely limited.

Questions/purposes

We asked: (1) How much variation is there between hospitals in episode-of-care payments for primary TKA? (2) Is variation in payment explained by differences in hospital structural characteristics such as teaching status or geographic location, patient factors (age, sex, ethnicity, comorbidities), and discharge disposition during the postoperative period (home versus skilled nursing facility)? (3) After accounting for those factors, what proportion of the observed variation remains unexplained?

Methods

We used Medicare administrative data to identify fee-for-service beneficiaries who underwent a primary elective TKA in 2009. After excluding low-volume hospitals, we created longitudinal records for all patients undergoing TKAs in eligible hospitals encompassing virtually all payments by Medicare for a 120-day window around the TKA (30 days before to 90 days after). We examined payments for the preoperative, perioperative, and postdischarge periods based on the hospital where the TKA was performed. Confounding variables were controlled for using multivariate analyses to determine whether differences in hospital payments could be explained by differences in patient demographics, comorbidity, or hospital structural factors.

Results

There was considerable variation in payments across hospitals. Median (interquartile range) hospital preoperative, perioperative, postdischarge, and 120-day payments for patients who did not experience a complication were USD 623 (USD 516-768), USD 13,119 (USD 12,165-14,668), USD 8020 (USD 6403-9933), and USD 21,870 (USD 19,736-25,041), respectively. Variation cannot be explained by differences in hospital structure. Median (interquartile range) episode payments were greater for hospitals in the Northeast (USD 26,291 [22,377-30,323]) compared with the Midwest, South, and West (USD 20,614, [USD 18,592-22.968]; USD 21,584, [USD 19,663-23,941]; USD 22,421, [USD 20,317-25,860]; p < 0.001) and for teaching compared with nonteaching hospitals (USD 23,152 [USD 20,426-27,127] versus USD 21,336 [USD 19,352-23,846]; p < 0.001). Patient characteristics explained approximately 15% of the variance in hospital payments, hospital characteristics (teaching status, geographic region) explained 30% of variance, and approximately 55% of variance was not explained by either factor.

Conclusions

There is much unexplained variation in episode-of-care payments at the hospital-level, suggesting opportunities for enhanced efficiency. Further research is needed to ensure an appropriate balance between such efficiencies and access to care.

Level of Evidence

Level II, economic analysis.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4445-0) contains supplementary material, which is available to authorized users.     

Interprofessional relationships between orthopaedic and podiatric surgeons in the UK

INTRODUCTION

The first comprehensive report on the interprofessional relationships between foot and ankle surgeons in the UK is presented.

MATERIALS AND METHODS

A questionnaire was sent to orthopaedic surgeons with membership of the British Foot and Ankle Surgery Society (BOFAS), orthopaedic surgeons not affiliated to the specialist BOFAS and podiatrists specialising in foot surgery. The questionnaire was returned by 77 (49%) of the BOFAS orthopaedic consultant surgeons, 66 (26%) of non-foot and ankle orthopaedic consultant surgeons and 99 (73%) of the podiatric surgeons.

RESULTS

While most respondents have experience of surgeons working in the other specialty in close geographical proximity, the majority do not believe that this has adversely affected their referral base. The experience of podiatrists of the outcomes of orthopaedic surgery has been more positive than orthopaedic surgeons of podiatric interventions. Podiatrists are more welcoming of future orthopaedic involvement in future foot and ankle services than in reverse. However, there are a sizeable number of surgeons in both professions who would like to see closer professional liaisons. The study has identified clear divisions between the professions but has highlighted areas where there is a desire from many clinicians to work more harmoniously together, such as in education, training and research.

CONCLUSIONS

While major concerns exist over issues such as surgery by non-registered medical practitioners and the suitable spectrum of surgery for each profession, many surgeons, in both professions, are willing to provide training for juniors in both specialties and there is a wish to have closer working relationships and common educational and research opportunities than exists at present.     

Knowledge of orthopaedic surgeons in managing patients with fragility fracture

Purpose

Fragility fractures represent a major health problem, as they cause deformity, disability and increased mortality rates. Orthopaedic surgeons should identify patients with fragility fractures and manage their osteoporosis in order to reduce the risk of future fracture; therefore, orthopaedic surgeons’ knowledge about managing fragile fracture should be evaluated.

Methods

A questionnaire was administered to 2,910 orthopaedic surgeons to address the respondents’ knowledge. The questions covered the topics of diagnosis, treatment and approach to a patient with a fragility fracture. The data-collection period for this survey spanned one year.

Results

There were 2,021 orthopaedic surgeons who participated in this study. Less than 10% of the respondents included bone mass densitometry (BMD) when evaluating patients with fragile fractures 32% prescribed proper dosage of calcium and vitamin D; approximately 30% would refer if falling from a height was suspected.

Conclusions

The majority of orthopaedic surgeons questioned lacked knowledge of fragility fracture management. This is reflected by limited knowledge of osteoporosis assessment and treatment in most areas. An appropriate method should be created to manage patients with fragility fractures to guarantee the patient the best possible care.     

Are the claims made in orthopaedic print advertisements valid?

Purpose

Advertisements are commonplace in orthopaedic journals and may influence the readership with claims of clinical and scientific fact. Since the last assessment of the claims made in orthopaedic print advertisements ten years ago, there have been legislative changes and media scrutiny which have shaped this practice. The purpose of this study is to re-evaluate these claims.

Methods

Fifty claims from 50 advertisements were chosen randomly from six highly respected peer-reviewed orthopaedic journals (published July–December 2011). The evidence supporting each claim was assessed and validated by three orthopaedic surgeons. The assessors, blinded to product and company, rated the evidence and answered the following questions: Does the evidence as presented support the claim made in the advertisement and what is the quality of that evidence? Is the claim supported by enough evidence to influence your own clinical practice?

Results

Twenty-eight claims cited evidence from published literature, four from public presentations, 11 from manufacturer "data held on file" and seven had no supporting evidence. Only 12 claims were considered to have high-quality evidence and only 11 were considered well supported. A strong correlation was seen between the quality of evidence and strength of support (Spearman r = 0.945, p < 0.0001). The average ICC between the assessors’ ratings was strong (r = 0.85) giving validity to the results.

Conclusion

Orthopaedic surgeons must remain sceptical about the claims made in print advertisements. High-quality evidence is required by orthopaedic surgeons to influence clinical practice and this evidence should be sought by manufacturers wishing to market a successful product.     

A Language for Effective Communication between Surgeons and Radiographers in Trauma Theatre

INTRODUCTION

The advent of the image intensifier has revolutionised trauma surgery since its development in 1955. The manufacturers have given names to various movements of the machine in the operating manual but it has not been popular among orthopaedic surgeons or radiographers. Lack of knowledge of names of various movements and ambiguity in command often leads to confusion between the surgeon and the radiographer regarding which way to move the image intensifier. A questionnaire-based study was conducted to assess the efficacy of communication between orthopaedic surgeons and radiographers while using the image intensifier intra-operatively.

SUBJECTS AND METHODS

Diagrams depicting the movements of the image intensifier were used in the questionnaire. Fifty questionnaires were given to orthopaedic surgeons and 50 to radiographers to name the various movements.

RESULTS

Ninety questionnaires were returned, 45 from surgeons and 45 from radiographers. Five questionnaires from surgeons and five from radiographers were returned blank. Of those responding, 97% could name the vertical movement, 68% the horizontal movement, 12% the swivel and 29% the angulation movement. None could name the orbital movement.

CONCLUSIONS

Even though orthopaedic surgeons do not operate the image intensifier themselves, knowledge of the movements of the image intensifier and their names can improve the efficacy of communication between surgeons and radiographers. A common language and precision in command can avoid confusion and has the potential to improve theatre time utilisation. The nomenclature of various movements of the image intensifier has been described and possible precise commands for various movements have been postulated.     

Factors Driving Physician-Hospital Alignment in Orthopaedic Surgery

Background

The relationships between physicians and hospitals are viewed as central to the proposition of delivering high-quality health care at a sustainable cost. Over the last two decades, major changes in the scope, breadth, and complexities of these relationships have emerged. Despite understanding the need for physician-hospital alignment, identification and understanding the incentives and drivers of alignment prove challenging.

Questions/purposes

Our review identifies the primary drivers of physician alignment with hospitals from both the physician and hospital perspectives. Further, we assess the drivers more specific to motivating orthopaedic surgeons to align with hospitals.

Methods

We performed a comprehensive literature review from 1992 to March 2012 to evaluate published studies and opinions on the issues surrounding physician-hospital alignment. Literature searches were performed in both MEDLINE^® and Health Business™ Elite.

Results

Available literature identifies economic and regulatory shifts in health care and cultural factors as primary drivers of physician-hospital alignment. Specific to orthopaedics, factors driving alignment include the profitability of orthopaedic service lines, the expense of implants, and issues surrounding ambulatory surgery centers and other ancillary services.

Conclusions

Evolving healthcare delivery and payment reforms promote increased collaboration between physicians and hospitals. While economic incentives and increasing regulatory demands provide the strongest drivers, cultural changes including physician leadership and changing expectations of work-life balance must be considered when pursuing successful alignment models. Physicians and hospitals view each other as critical to achieving lower-cost, higher-quality health care.     

How do Orthopaedic Devices Change After Their Initial FDA Premarket Approval?

Background

The FDA approves novel, high-risk medical devices through the premarket approval (PMA) process based on clinical evidence supporting device safety and effectiveness. Devices subsequently may undergo postmarket modifications that are approved via one of several PMA supplement review tracks, usually without additional supporting clinical data. While orthopaedic devices cleared via the less rigorous 510(k) pathway have been studied previously, devices cleared through the PMA pathway and those receiving postmarket PMA supplements warrant further investigation.

Questions/purposes

We asked: What are (1) the types of original orthopaedic devices receiving FDA PMA approval, (2) the number and rate of postmarket device changes approved per device, (3) the types of PMA supplement review tracks used, (4) the types of device changes approved via the various review tracks, and (5) the number of device recalls and market withdrawals that have occurred for these devices?

Methods

All original PMA-approved orthopaedic devices between January 1982 and December 2014 were identified in the publically available FDA PMA database. The number of postmarket device changes approved, the PMA supplement review track used, the types of postmarket changes, and any FDA recalls for each device were assessed.

Results

Seventy original orthopaedic devices were approved via the FDA PMA pathway between 1982 and 2014. These devices included 34 peripheral joint implants or prostheses, 18 spinal implants or prostheses, and 18 other devices or materials. These devices underwent a median 6.5 postmarket changes during their lifespan or 1.0 changes per device–year (interquartile range, 0.4–1.9). The rate of new postmarket device changes approved per active device, increased from less than 0.5 device changes per year in 1983 to just fewer than three device changes per year in 2014, or an increase of 0.05 device changes per device per year in linear regression analysis (95% CI, 0.04–0.07). Among the 765 total postmarket changes, 172 (22%) altered device design or components. The majority of the design changes were reviewed via either the real-time review track (n = 98; 57%), intended for minor design changes, or the 180-day review track (n = 71; 41%), intended for major design changes. Finally, a total of 12 devices had FDA recalls at some point during their lifespan, two being for hip prostheses with high revision rates.

Conclusions

Relatively few orthopaedic devices undergo the FDA PMA process before reaching the market. Orthopaedic surgeons should be aware that high-risk medical devices cleared via the FDA’s PMA pathway do undergo considerable postmarket device modification after reaching the market, with potential for design “drift,” ie, shifting away from the initially tested and approved device designs.

Clinical Relevance

As the ultimate end-users of these devices, orthopaedic surgeons should be aware that even among high-risk medical devices approved via the FDA’s PMA pathway, considerable postmarket device modification occurs. Continued postmarket device monitoring will be essential to limit patient safety risks.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4634-x) contains supplementary material, which is available to authorized users.     

Patient decision aids in joint replacement surgery: a literature review and an opinion survey of consultant orthopaedic surgeons

INTRODUCTION

Patient decision aids could facilitate shared decision-making in joint replacement surgery. However, patient decision aids are not routinely used in this setting.

METHODS

With a view to developing a patient decision aid for UK hip/knee joint replacement practice, we undertook a systematic search of the literature for evidence on the use of shared decision-making and patient decision aids in orthopaedics, and a national survey of consultant orthopaedic surgeons on the potential acceptability and feasibility of patient decision aids.

RESULTS

We found little published evidence regarding shared decision-making or patient decision aids in orthopaedics. In the survey, 362 of 639 (57%) randomly selected consultant orthopaedic surgeons responded. Respondents appear representative of consultant orthopaedic surgeons in the UK. Of 272 valid responses, 79% (95% CI, 73–85%) thought patient decision aids a good or excellent idea. There was consensus on the potential helpfulness of patient decision aids and core content. A booklet to take home was the preferred medium/practice model.

CONCLUSIONS

Despite the increased emphasis on patient involvement in decision-making, there is little evidence in the medical literature relating to shared decision-making or the use of patient decision aids in orthopaedic surgery. Further research in this area of clinical practice is required. Our survey shows that consultant orthopaedic surgeons in the UK are generally positive about the use of patient decision aids for joint replacement surgery. Survey results could inform future development of patient decision aids for joint replacement practice in the UK.     

Chronic stress and coping among cardiac surgeons: a single center study

Introduction

Cardiac surgeons stress may impair their quality of life and professional practice.

Objective

To assess perceived chronic stress and coping strategies among cardiac surgeons.

Methods

Twenty-two cardiac surgeons answered two self-assessment questionnaires, the Trier Inventory for Chronic Stress and the German SGV for coping strategies.

Results

Participants mean age was 40±14.1 years and 13 were male; eight were senior physicians and 14 were residents. Mean values for the Trier Inventory for Chronic Stress were within the normal range. Unexperienced physicians had significantly higher levels of dissatisfaction at work, lack of social recognition, and isolation (P<0.05). Coping strategies such as play down, distraction from situation, and substitutional satisfaction were also significantly more frequent among unexperienced surgeons. "Negative" stress-coping strategies occur more often in experienced than in younger colleagues (P=0.029). Female surgeons felt more exposed to overwork (P=0.04) and social stress (P=0.03).

Conclusion

Cardiac surgeons show a tendency to high perception of chronic stress phenomena and vulnerability for negative coping strategies.     

The prevalence of bifid iliopsoas tendon on MRI in children

Objective

The variation in the anatomy of the iliopsoas tendon is important information for orthopaedic surgeons operating around the hip. The aim of this study was to identify the prevalence of bifid iliopsoas tendons in children on magnetic resonance imaging (MRI).

Methods

MRI hip and pelvis images of 50 sequential children aged 7–15 years were retrieved from our radiology database at the Evelina London Children’s Hospital from 2007 to 2013. Included were 37 children with imaging of both hips and 13 children with imaging of one hip only. Therefore, our study was based on a total of 87 hips.

Results

At least 1 bifid tendon was noted in 13 children (26 %). Five children from a total of 37 (14 %) with both hips adequately imaged had bilateral bifid tendons. Among all 87 adequately imaged hips, 18 (21 %) were found to have two discrete distal iliopsoas tendons.

Conclusions

Bifid iliopsoas tendon is noted anecdotally by surgeons but was only reported in scattered case reports and a few anatomical studies until very recently. Our finding is that a bifid iliopsoas tendon with two distinct tendinous components at the level of the hip joint is quite common. This has clinical significance, particularly in children’s orthopaedic surgery when an adequate iliopsoas release is important.     

Surgery in Malawi - a national survey of activity in rural and urban hospitals

INTRODUCTION

Malawi is a poor country with few doctors. It has 21 district hospitals all of which have operating theatres but none of which has a permanent surgeon. It also has 4 central hospitals, each with one or more surgeons. Most district hospitals are manned by a single doctor and two or more paramedical clinical officers.

PATIENTS AND METHODS

All district and central hospitals were visited, and theatre logbooks analysed. All cases performed in 2003 were recorded.

RESULTS

In 2003, a total of 48,696 surgical operations were recorded, of which 25,053 were performed in 21 district hospitals and 23,643 in 4 central hospitals. Caesarean section is the commonest major surgical procedure in district hospitals and is performed in approximately 2.8% of all births, compared to 22% in the UK. Very few major general surgical or orthopaedic procedures are carried out in district hospitals.

CONCLUSION

This study underlines Malawi''s need for more surgeons to be trained and retained.     

The accuracy of digital templating: a comparison of short-stem total hip arthroplasty and conventional total hip arthroplasty

Purpose

Selection of the correct femoral stem size is crucial in total hip arthroplasty for an uncomplicated implantation and good initial stability. Pre-operative templating has been shown to be a valuable tool in predicting the correct implant size. For short-stem total hip arthroplasty (SHA), which recently is increasingly used, it is unknown if templating can be performed as reliable as conventional total hip arthroplasty (THA).

Methods

A total of 100 hip arthroplasties, 50 with SHA and 50 with THA, were templated by four orthopaedic surgeons each. The surgeons had different levels of professional experience and performed a digital template of the acetabular and femoral component on the pre-operative radiographs. The results were compared with the truly inserted implant size.

Results

For the femoral stems the average percentage of agreement (±1 size) was 89.0 % in SHA and 88.5 % in THA. There was no significant difference among surgeons in the accuracy of templating the correct stem size and no significant difference between templating SHA and THA. For the acetabular component the average percentage of agreement (±1 size) was 75.8 %. However, the more experienced surgeons showed a significant higher accuracy for templating the correct cup size than the less experienced surgeons.

Conclusion

Digital templating of SHA can predict the stem sizes as accurately as conventional THA. Therefore digital templating is also recommendable for SHA, as it helps to predict the implant size prior to surgery and thereby might help to avoid complications.     

Training in the practical application of damage control and early total care operative philosophy �C perceptions of UK orthopaedic specialist trainees

INTRODUCTION

Despite improvements in the outcome of individuals sustaining significant injury, the optimum management of fractures in traumatised patients remains an area of debate and publication. There is, however, a paucity of studies regarding the specifics of acquired experience and training of junior orthopaedic surgeons in the practical application of these skills. Our null hypothesis is that, despite alteration in surgical training, the perceived confidence and adequacy of training of UK orthopaedic specialist trainees in the application of damage control orthopaedics (DCO) and early total care (ETC) philosophy is unaffected.

PATIENTS AND METHODS

A web-based survey was sent to a sample of orthopaedic trainees. From 888 trainees, 222 responses were required to achieve a 5% error rate with 90% confidence.

RESULTS

A total of 232 responses were received. Trainees reported a high level of perceived confidence with both external fixation and intramedullary devices. Exposure to cases was sporadic although perceived training adequacy was high. A similar pattern was seen in perceived operative role with the majority of trainees expecting to be performing such operations, albeit under varying levels of supervision. In a more complicated case of spanning external fixation for a ‘floating knee, trainees reported a decreased level of perceived confidence and limited exposure. One-third of trainees reported never having been involved in such a case. In contrast to nationally collated logbook data, exposure to and perceived confidence in managing cases involving ETC and DCO were similar.

CONCLUSIONS

Despite changes in the training of junior orthopaedic surgeons, trainee-reported confidence and adequacy of training in the practical application of DCO and ETC was high. Exposure to cases overall was, however, seen to be limited and there was a suggestion of disparity between current operative experiences of trainees and that recorded in the national trainee logbook.     

Patients' misunderstanding of common orthopaedic terminology: the need for clarity

INTRODUCTION

Patients'' understanding of their medical problems is essential to allow them to make competent decisions, comply with treatment and enable recovery. We investigated Patients'' understanding of orthopaedic terms to identify those words surgeons should make the most effort to explain.

METHODS

This questionnaire-based study recruited patients attending the orthopaedic clinics. Qualitative and quantitative data were collected using free text boxes for the Patients'' written definitions and multiple choice questions (MCQs).

RESULTS

A total of 133 patients took part. Of these, 74% identified English as their first language. ‘Broken bone’ was correctly defined by 71% of respondents whereas ‘fractured bone’ was only correctly defined by 33%. ‘Sprain’ was correctly defined by 17% of respondents, with 29% being almost correct, 25% wrong and 29% unsure. In the MCQs, 51% of respondents answered correctly for ‘fracture’, 55% for ‘arthroscopy’, 46% for ‘meniscus’, 35% for ‘tendon’ and 23% for ‘ligament’. ‘Sprained’ caused confusion, with only 11% of patients answering correctly. Speaking English as a second language was a significant predictive factor for patients who had difficulty with definitions. There was no significant variation among different age groups.

CONCLUSIONS

Care should be taken by surgeons when using basic and common orthopaedic terminology in order to avoid misunderstanding. Educating patients in clinic is a routine part of practice.     

Financial implications of plans to combat methicillin-resistant Staphylococcus aureus (MRSA) in an orthopaedic department

INTRODUCTION

The aim of this study was to calculate retrospectively the cost of MRSA infections in the elective and trauma orthopaedic population in Rotherham District General Hospital in a 3-month period during 2005.

PATIENTS AND METHODS

A total of 686 patients were admitted to the orthopaedic wards and the surgical wounds 10 patients became infected with MRSA.

RESULTS

The cost of these infections when extrapolated over 12 months was £384,000 excluding staff costs.

CONCLUSIONS

The key in the fight against MRSA in the hospital setting is multifactorial and requires a combination of measures. Our solution is: cohort nursing; non-selective screening of all admissions to the orthopaedic wards; use of a polymerase chain reaction as a diagnostic tool; ring-fencing of beds; and separate wound dressing rooms for each ward. The total cost is projected to be £301,000.     

How Prevalent Are Hazardous Attitudes Among Orthopaedic Surgeons?

Background

So-called “hazardous attitudes” (macho, impulsive, antiauthority, resignation, invulnerable, and confident) were identified by the Federal Aviation Administration and the Canadian Air Transport Administration as contributing to road traffic incidents among college-aged drivers and felt to be useful for the prevention of aviation accidents. The concept of hazardous attitudes may also be useful in understanding adverse events in surgery, but it has not been widely studied.

Questions/purposes

We surveyed a cohort of orthopaedic surgeons to determine the following: (1) What is the prevalence of hazardous attitudes in a large cohort of orthopaedic surgeons? (2) Do practice setting and/or demographics influence variation in hazardous attitudes in our cohort of surgeons? (3) Do surgeons feel they work in a climate that promotes patient safety?

Methods

We asked the members of the Science of Variation Group—fully trained, practicing orthopaedic and trauma surgeons from around the world—to complete a questionnaire validated in college-aged drivers measuring six attitudes associated with a greater likelihood of collision and used by pilots to assess and teach aviation safety. We accepted this validation as applicable to surgeons and modified the questionnaire accordingly. We also asked them to complete the Modified Safety Climate Questionnaire, a questionnaire assessing the absence of a safety climate that is based on the patient safety cultures in healthcare organizations instrument. Three hundred sixty-four orthopaedic surgeons participated, representing a 47% response rate of those with correct email addresses who were invited.

Results

Thirty-eight percent (137 of 364 surgeons) had at least one score that would have been considered dangerously high in pilots (> 20), including 102 with dangerous levels of macho (28%) and 41 with dangerous levels of self-confidence (11%). After accounting for possible confounding variables, the variables most closely associated with a macho attitude deemed hazardous in pilots were supervision of surgical trainees in the operating room (p = 0.003); location of practice in Canada (p = 0.059), Europe (p = 0.021), and the United States (p = 0.005); and being an orthopaedic trauma surgeon (p = 0.046) (when compared with general orthopaedic surgeons), but accounted for only 5.3% of the variance (p < 0.001). On average, 19% of surgeon responses to the Modified Safety Climate Questionnaire implied absence of a safety climate.

Conclusions

Hazardous attitudes are common among orthopaedic surgeons and relate in small part to demographics and practice setting. Future studies should further validate the measure of hazardous attitudes among surgeons and determine if they are associated with preventable adverse events. We agree with aviation safety experts that awareness of amelioration of such attitudes might improve safety in all complex, high-risk endeavors, including surgery—a line of thinking that merits additional research.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-3966-2) contains supplementary material, which is available to authorized users.