Faculty Bibliography

BACKGROUND:Smoking is associated with adverse outcomes after total joint arthroplasty (TJA), including periprosthetic joint infection (PJI). Although preoperative smoking cessation interventions may help reduce the risk PJI, the short-term cost-effectiveness of these programs remains unclear. METHODS:Decision analysis was used to evaluate the cost-effectiveness of a preoperative smoking cessation intervention over a 90-day TJA episode of care. Costs and probabilities were derived from literature review and published Medicare data. Thresholds for cost and efficacy of the intervention were determined using sensitivity analysis. RESULTS:In our model, the average 90-day cost was $32 less for patients enrolled in a mandatory smoking cessation intervention ($23,457) compared with patients who were not ($23,489). In sensitivity analyses, the smoking cessation intervention was cost-saving vs no intervention when the short-term cost of PJI was greater than $95,410, the rate of PJI was reduced by at least 25% for former vs current smokers, the cost of the intervention was less than $219, or the success rate of the intervention was greater than 56%. CONCLUSION/CONCLUSIONS:Smoking cessation interventions prior to TJA can increase the value of care and are an important public health initiative. Routine referral to smoking cessation interventions should be considered for smokers indicated for TJA. LEVEL OF EVIDENCE/METHODS:Level II, economic and decision analyses.

Alternative payment models are constantly evolving in an attempt to create value by decreasing cost while improving or maintaining quality. The Bundled Payments for Care Improvement initiative was implemented in 2011, and many institutions have seen early success by using the seven pillars of total joint arthroplasty episode management. Private insurers have seen improvements in care and cost savings by adopting private bundle programs. In each organization, alignment among all stakeholders is paramount to the success of the bundled payment programs. Gainsharing offers a unique opportunity to incentivize physicians to change their care practices in an attempt to reduce costs and improve outcomes. As bundled payments evolve, the cooperation of physicians, health care institutions, payers, and patients will lead to value creation for all stakeholders.

The Centers for Medicare & Medicaid Services is committed to moving 50% of its fee-for-service care to value-based alternative payment models by 2018. The Comprehensive Care for Joint Replacement model is a mandatory agency program that bundles lower extremity joint arthroplasties into episodes of care that extend from the index admission to 90 days after discharge. This program, which began on April 1, 2016, includes many of the hospitals that perform total joint arthroplasties. As with other bundled payment arrangements, this model is built around seven principles that orthopaedic surgeons should be familiar with to maximize participation.

BACKGROUND:Health disparities exist among many patient populations, with race, payer status, hospital size and access to teaching versus non-teaching hospitals potentially affecting whether certain patients have access to the benefits of total wrist arthroplasty (TWA). METHODS:The National Inpatient Sample Database (NIS) was queried from 2001 to 2013 for TWA using the ICD-9 code 81.73. Patient-level data included age, sex, race, payer status, and year of discharge. Hospital-level data included hospital bed size, location, teaching status, and region. RESULTS:There were 1,213 patients identified who underwent TWA between 2001 and 2013. Total number of procedures decreased from 88 TWAs in 2001 to 65 in 2013. The yearly volume ranged from 33 in 2005 to 128 in 2007. The male-female ratio was 2.5 to 1. The majority of TWA procedures were performed at urban teaching hospitals (60.8%). CONCLUSIONS:The NIS database shows a downward trend of total wrist arthroplasty utilization. The majority of total wrist arthroplasties were performed at urban teaching hospitals indicating treatment occurs most often at academic centers of excellence.

BACKGROUND:We sought to investigate how patient demographics and baseline comorbidities varied between hip fracture and total joint arthroplasty patients across New York State and to determine implications of differences within the contexts of the bundled payment system. METHODS:All Medicare hip and knee arthroplasty and hip fracture cases in the New York State SPARCS database between 2004 and 2014 were identified. Hospitals were categorized geographically into Metropolitan Statistical Areas (MSAs) to determine case distribution. Baseline comorbidities and patient characteristics were stratified. RESULTS:A total of 218,300 cases were identified; 187,720 arthroplasties and 30,580 hip fractures. The distribution of total cases was significantly skewed toward large MSAs and there was wide variability in the arthroplasty/fracture ratio. Despite similar baseline patient age and gender distributions, there were significant inconsistencies observed in comorbidity burden and length of stay between MSAs. While every MSA had higher average comorbidity scores and longer average lengths of stay in the hip fracture cases than the arthroplasty cases, there was also additional variability observed in the hip fracture cases between each MSA. CONCLUSION/CONCLUSIONS:The unpredictability observed in hip fracture cases compared to elective arthroplasty can make cost containment in a bundled payment system difficult, particularly for hospitals serving sicker patient populations.

Accuracy of component and limb alignment are critical parameters for the long-term success of unicompartmental knee implants. In this study, we performed a laboratory evaluation of an instrumentation system which was designed for an early intervention (EI) type of unicompartmental knee. The accuracy of fit was evaluated by implanting in 20 sawbones full leg models. The overall alignment of the limb was compared pre- and postoperatively. The accuracy of placement of each component on its bone was measured. The mean overall alignment angle in the frontal plane was within 1° of target with less than 1° standard deviation. The components were positioned in frontal and sagittal planes with maximum errors of 2°. The angular accuracy was better than in studies reported in the literature for manual instruments, and almost approached the accuracy of computer-assisted systems. The position of the femoral component in the recess was within 1 mm in most cases but the sagittal flexion angle was variable with a standard deviation of 6°. Evaluation of a surgical technique in this way was a valuable method for determining accuracy and for highlighting any deficiencies in the system which could then be corrected.

In recent years, narcotics have been subject to increased regulation and monitoring because of their side effects and potential for misuse. Currently, variation in prescribing patterns of narcotics among orthopedic surgeons is unknown. The Medicare Part D claims database was used to identify orthopedic surgeons who prescribed at least one schedule II or III narcotic during 2014. The median duration of a narcotic prescription was 8.2 days. The median prescription duration was shortest for hand surgeons (5.6 days) and longest for spine surgeons (12.6 days). Orthopedic surgeons in New York (10.1 days) provided the most narcotics per prescription, with physicians in Vermont (6.2 days) providing the least. Substantial variation exists in narcotic prescribing patterns for orthopedic surgeons at the individual, subspecialty, and statewide levels. With public health focus on reducing narcotics abuse, physician stewardship of these medications will become increasingly relevant.

BACKGROUND:The purpose of this study was to examine the geographic and demographic variations and time trends of different types of meniscal procedures in New York State to determine whether disparities exist in access to treatment. METHODS:The New York Statewide Planning and Research Cooperative System (SPARCS) outpatient database was reviewed to identify patients who underwent elective, primary knee arthroscopy between January 1, 2003, and December 31, 2015, for 1 of the following diagnosis-related categories: Group 1, meniscectomy; Group 2, meniscal repair; and Group 3, meniscal allograft transplantation, with or without anterior cruciate ligament reconstruction (ACLR). The 3 groups of meniscal procedures were compared on geographic distribution, patient age, insurance, concomitant ACLR, and surgeon and hospital volume over the study period. RESULTS:A total of 649,470 patients who underwent knee arthroscopy between 2003 and 2015 were identified for analysis. Both meniscectomies and meniscal repairs had a scattered distribution throughout New York State, with allograft volume concentrated at urban academic hospitals. The majority of patients who underwent any meniscal procedure had private insurance, with Medicaid patients having the lowest rates of meniscal surgery. At high-volume hospitals, meniscal repairs and allografts are being performed with increasing frequency, especially in patients <25 years of age. Meniscal repairs are being performed concomitantly with ACLR with increasing frequency. CONCLUSIONS:Meniscal repairs and allografts are being performed at high-volume hospitals for privately insured patients with increasing frequency. Geographic access to these treatments, particularly allografts, is limited. CLINICAL RELEVANCE/CONCLUSIONS:Disparities in the availability of advanced meniscal treatment require further investigation and understanding to improve access to care.