Faculty Bibliography

BACKGROUND:The Comprehensive Care for Joint Replacement requires patient-reported outcome measure (PROM) completion for total knee/hip arthroplasty (TKA/THA) patients. A 90% completion rate to avoid penalties was planned for 2023 but has been delayed. Our analysis compares TKA/THA PROM completion and results across demographics. We hypothesized that minority groups would be less likely to complete PROMs. METHODS:A retrospective review was performed from 2018 to 2021 of 16,119 patients who underwent primary elective TKA or THA at a single institution. Pairwise chi-squared tests, t-tests, analysis of variance, and multiple logistic regression analyses were used to compare PROM completion rates and scores across demographics and surgery type (TKA/THA). RESULTS:Comparing patients who had (N = 7,664) and did not have (N = 8,455) documented PROMs, completion rates were significantly lower in patients who were women, Black, Hispanic, less educated, used Medicaid insurance, lived in lower income neighborhoods, spoke non-English languages, required an interpreter, and underwent TKA versus THA. After regression analyses, odds ratios for PROM completion remained significantly lower in non-English speakers, Hispanic and Medicaid patients, lower income groups, and patients undergoing TKA. For the 31.8% of patients who completed both preoperative/postoperative PROMs, women, Black, and non-English speaking patients had significantly lower PROM scores for most measures preoperatively and postoperatively despite similar or better improvements after surgery. CONCLUSION/CONCLUSIONS:Patients undergoing TKA and non-English speaking, ethnic, and socioeconomic minorities are less likely to complete PROMs. Strategies to create, validate, and collect PROMs for these populations are needed to avoid exacerbation of healthcare disparities.

BACKGROUND:Over the past decade, reimbursement models and target payments have been modified in an effort to decrease costs of revision total knee arthroplasty (rTKA) while maintaining the quality of care. The goal of this study was to investigate trends in revenue and costs associated with rTKA. METHODS:We retrospectively reviewed all patients who underwent rTKA between 2011 and 2021 at our institution. Patients were stratified into groups based on insurance coverage: Medicare, government-managed or Medicaid (GMM), or commercial insurance. Patient demographics were collected, as well as revenue, costs, and contribution margin (CM) of the inpatient episode. Changes over time as a percentage of 2011 numbers were analyzed. Linear regressions were used to determine trend significance. In the 10-year study period, 1,698 patients were identified with complete financial data. RESULTS:Overall total cost has increased significantly (P < .01). While revenues and CM for Medicare and Commercial patients remained steady between 2011 and 2021, CM for GMM patients decreased significantly (P = .01) to a low of 53.2% of the 2011 values. Since 2018, overall CM and revenues decreased significantly (P = .05, P = .01, respectively). CONCLUSION/CONCLUSIONS:While from 2011 to 2018 general revenues and CM were relatively steady, since 2018 they have decreased significantly to their lowest values in over a decade for GMM and commercial patients. This trend is concerning and may potentially lead to decreased access to care. Re-evaluation of reimbursement models for rTKA may be necessary to ensure the financial viability of this procedure and prevent issues with access to care. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Revision total hip arthroplasty (rTHA) is a costly procedure, and its prevalence has been steadily increasing over time. This study aimed to examine trends in hospital cost, revenue, and contribution margin (CM) in patients undergoing rTHA. METHODS:We retrospectively reviewed all patients who underwent rTHA from June 2011 to May 2021 at our institution. Patients were stratified into groups based on insurance coverage: Medicare, government-managed Medicaid, or commercial insurance. Patient demographics, revenue (any payment the hospital received), direct cost (any cost associated with the surgery and hospitalization), total cost (the sum of direct and indirect costs), and CM (the difference between revenue and direct cost) were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analyses were used to determine the overall trend's significance. Of the 1,613 patients identified, 661 were covered by Medicare, 449 by government-managed Medicaid, and 503 by commercial insurance plans. RESULTS:Medicare patients exhibited a significant upward trend in revenue (P < .001), total cost (P = .004), direct cost (P < .001), and an overall downward trend in CM (P = .037), with CM for these patients falling to 72.1% of 2011 values by 2021. CONCLUSION/CONCLUSIONS:In the Medicare population, reimbursement for rTHA has not matched increases in cost, leading to considerable reductions in CM. These trends affect the ability of hospitals to cover indirect costs, threatening access to care for patients who require this necessary procedure. Reimbursement models for rTHA should be reconsidered to ensure the financial feasibility of these procedures for all patient populations.

BACKGROUND:The impact of preoperative nasal colonization with methicillin resistant staphylococcus aureus (MRSA) on total joint arthroplasty (TJA) outcomes is not well understood. This study aimed to evaluate complications following TJA based on patients' preoperative staphylococcal colonization status. METHODS:We retrospectively analyzed all patients undergoing primary TJA between 2011 and 2022 who completed a preoperative nasal culture swab for staphylococcal colonization. Patients were 1:1:1 propensity matched using baseline characteristics, and stratified into 3 groups based on their colonization status: MRSA positive (MRSA+), methicillin sensitive staphylococcus aureus positive (MSSA+), and MSSA/MRSA negative (MSSA/MRSA-). All MRSA+ and MSSA + underwent decolonization with 5% povidone iodine, with the addition of intravenous vancomycin for MRSA + patients. Surgical outcomes were compared between groups. Of the 33,854 patients evaluated, 711 were included in final matched analysis (237 per group). RESULTS:The MRSA + TJA patients had longer hospital lengths of stay (P = .008), were less likely to discharge home (P = .003), and had higher 30-day (P = .030) and 90-day (P = .033) readmission rates compared to MSSA+ and MSSA/MRSA-patients, though 90-day major and minor complications were comparable across groups. MRSA + patients had higher rates of all-cause (P = .020), aseptic (P = .025) and septic revisions (P = .049) compared to the other cohorts. These findings held true for both total knee and total hip arthroplasty patients when analyzed separately. CONCLUSION/CONCLUSIONS:Despite targeted perioperative decolonization, MRSA + patients undergoing TJA have longer lengths of stay, higher readmission rates, and higher septic and aseptic revision rates. Surgeons should consider patients' preoperative MRSA colonization status when counseling on the risks of TJA.

INTRODUCTION/BACKGROUND:Length of stay (LOS) and readmissions are quality metrics linked to physician payments and substantially impact the cost of care. This study aims to evaluate the effect of documented and undocumented psychiatric conditions on LOS, discharge location, and readmission following total knee arthroplasty (TKA). METHODS:Retrospective review of all primary, unilateral TKA from 2015 to 2020 at a high-volume, academic orthopedic hospital was conducted. Patients were separated into three cohorts: patients with a documented psychiatric diagnosis (+Dx), patients without a documented psychiatric diagnosis but with an actively prescribed psychiatric medication (-Dx), and patients without a psychiatric diagnosis or medication (control). Patient demographics, LOS, discharge location, and 90 days readmissions were assessed. RESULTS:A total of 2935 patients were included; 1051 patients had no recorded psychiatric medications (control); 1884 patients took at least one psychiatric medication, of which 1161 (61.6%) were in the-Dx and 723 (38.4%) were in the +Dx cohort. Operative time (+Dx, 103.4 ± 29.1 and -Dx, 103.1 ± 28.5 vs. 93.6 ± 26.2 min, p < 0.001 for both comparisons) and hospital LOS stay (+ Dx, 3.00 ± 1.70 and -Dx, 3.01 ± 1.83 vs. 2.82 ± 1.40 days, p = 0.021 and p = 0.006, respectively) were greater for patients taking psychiatric medications when compared to the control group. Patients taking psychiatric medication with or without associated diagnosis were significantly more likely to be discharged to a secondary facility-22.8% and 20.9%, respectively-compared to controls, at 12.5% (p < 0.001). Ninety-day readmission rates did not differ between the control and both psychiatric groups (p = 0.693 and p = 0.432, respectively). CONCLUSION/CONCLUSIONS:TKA patients taking psychiatric medications with or without a documented psychiatric diagnosis have increased hospital LOS and higher chances of discharge to a secondary facility. Most patients taking psychiatric medication also had no associated diagnosis. Payment models should consider the presence of undocumented psychiatric diagnoses when constructing metrics. Surgeons and institutions should also direct their attention to identifying, recording, and managing these patients to improve outcomes. LEVEL III EVIDENCE/METHODS:Retrospective Cohort Study.

INTRODUCTION/BACKGROUND:Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only (IPO) list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty (TJA) surgery. METHODS:We reviewed all patients who underwent TKA or THA after these procedures were removed from the IPO list. Patients were stratified into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-square tests. RESULTS:Among Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (p<0.001), though there was no significant difference between cohorts for TKA (p=0.501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (p<0.001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (p<0.001). CONCLUSION/CONCLUSIONS:Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at risk of losing access to care.

INTRODUCTION/BACKGROUND:The effect of vaping on outcomes after total joint arthroplasty (TJA) and its prevalence in this patient population remain unclear. The purpose of this study was twofold: (1) to investigate the trends of vaping in TJA patients compared with patients who underwent routine physical examination and (2) to examine the influence vaping has on outcomes after TJA. METHODS:Patients were classified as never vaped, former vape users, or whether they reported current vaping (CV). TJA patients were further classified based on whether they had no exposure to tobacco or vaping (NTNV), tobacco only (TO), both tobacco and vaping (BTV), or vaping only (VO). RESULTS:The TJA group exhibited a steady trend of patients with CV status (P = 0.540) while patients in the routine physical examination cohort demonstrated a significant upward trend in CV status (P = 0.015). Subanalysis of TJA patients revealed that those in the VO category had significantly higher mean surgical time (P < 0.001), length of stay (P = 0.01), and rates of readmission (P = 0.001) compared with all other subgroups. CONCLUSION/CONCLUSIONS:We found steady or increasing trends of electronic cigarette exposure in both groups over time. Additional efforts should be made to document electronic cigarette exposure for all patients.

Non-English-speaking patients face increased communication barriers when undergoing total joint arthroplasty (TJA). Surgeons may learn or have proficiency in languages spoken among their patients to improve communication. This study investigated the effect of surgeon-patient language concordance on outcomes after TJA. We conducted a single-institution, retrospective review of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) whose preferred language was not English. Patients were stratified based on whether their surgeon spoke their preferred language (language concordant [LC]) or not (language discordant [LD]). Baseline characteristics, length of stay, discharge disposition, revision rate, readmission rate, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS, JR], Hip disability and Osteoarthritis Outcome Score for Joint Replacement [HOOS, JR], and Patient-Reported Outcomes Measurement Information System [PROMIS]) were compared. A total of 3390 patients met inclusion criteria, with 855 receiving THA and 2535 receiving TKA. Among patients receiving THA, 440 (51.5%) saw a LC provider and 415 (48.5%) saw a LD provider. Those in the LC group had higher HOOS, JR scores at 1 year postoperatively (67.4 vs 49.3, P=.003) and were more likely to be discharged home (77.5% vs 69.9%, P=.013). Among patients receiving TKA, 1051 (41.5%) received LC care, whereas 1484 (58.5%) received LD care. There were no differences in outcome between the LC and LD TKA groups. Patients receiving THA with surgeons who spoke their language had improved patient-reported outcomes and were more commonly discharged home after surgery. Language concordance did not change outcomes in TKA. Optimizing language concordance for patients receiving TJA may improve postoperative outcomes. [Orthopedics. 2023;46(6):334-339.].

Non-English-speaking patients face increased communication barriers when undergoing total joint arthroplasty (TJA). Surgeons may learn or have proficiency in languages spoken among their patients to improve communication. This study investigated the effect of surgeon-patient language concordance on outcomes after TJA. We conducted a single-institution, retrospective review of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) whose preferred language was not English. Patients were stratified based on whether their surgeon spoke their preferred language (language concordant [LC]) or not (language discordant [LD]). Baseline characteristics, length of stay, discharge disposition, revision rate, readmission rate, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS, JR], Hip disability and Osteoarthritis Outcome Score for Joint Replacement [HOOS, JR], and Patient-Reported Outcomes Measurement Information System [PROMIS]) were compared. A total of 3390 patients met inclusion criteria, with 855 receiving THA and 2535 receiving TKA. Among patients receiving THA, 440 (51.5%) saw a LC provider and 415 (48.5%) saw a LD provider. Those in the LC group had higher HOOS, JR scores at 1 year postoperatively (67.4 vs 49.3, P=.003) and were more likely to be discharged home (77.5% vs 69.9%, P=.013). Among patients receiving TKA, 1051 (41.5%) received LC care, whereas 1484 (58.5%) received LD care. There were no differences in outcome between the LC and LD TKA groups. Patients receiving THA with surgeons who spoke their language had improved patient-reported outcomes and were more commonly discharged home after surgery. Language concordance did not change outcomes in TKA. Optimizing language concordance for patients receiving TJA may improve postoperative outcomes. [Orthopedics. 2023;46(6):334-339.].