Faculty Bibliography

BACKGROUND: Hip arthroplasty is increasingly performed as a treatment for femoral neck fractures (FNFs). However, these cases have higher complication rates than elective total hip arthroplasties (THAs). The Center for Medicare and Medicaid Services has created the Comprehensive Care for Joint Replacement model to increase the value of patient care. This model risk stratifies FNF patients in an attempt to appropriately allocate resources, but the formula has not been disclosed. The goal of this study was to ascertain if patients with FNFs have different readmission rates compared to patients undergoing elective THA so that the resource utilization can be assessed. METHODS: We analyzed all patients undergoing THA at our institution during a 21-month period. Patients classified by a diagnosis-related group of 469 or 470 were included. Multivariate and survival analyses were performed to determine risk of 90-day readmission. RESULTS: Patients admitted for FNFs were older, had higher body mass indices, longer lengths of stay, and were more likely to be discharged to inpatient facilities than patients who underwent elective THA. Increased American Society of Anesthesiologists scores and FNF were also independent risk factors for 90-day readmission, and these patient were more likely to be readmitted during the latter 60 days following admission. CONCLUSION: Results suggest that patients who undergo an arthroplasty following urgent or emergent FNFs have inferior outcomes to those receiving an arthroplasty for a diagnosis of arthritis. Fracture patients should either be risk stratified to allow appropriate resource allocation or be excluded from alternative payment initiatives such as Comprehensive Care for Joint Replacement.

INTRODUCTION: Staphylococcus aureus (S aureus) decolonization regimens are being used to mitigate the risk of surgical site infection (SSI). However, their efficacy is controversial, with mixed results reported in the literature. METHODS: Before undergoing primary total knee arthroplasty (TKA), total hip arthroplasty (THA), or spinal fusion, 13,828 consecutive patients were screened for nasal S aureus and underwent a preoperative decolonization regimen. Infection rates of colonized and noncolonized patients were compared using unadjusted logistic regression. An adjusted regression analysis was performed to determine independent risk factors for SSI. RESULTS: The rate of SSI in colonized patients was 4.35% compared with only 2.39% in noncolonized patients. In our TKA cohort, unadjusted logistic regression identified S aureus colonization to be a significant risk factor for SSI (odds ratio [OR], 2.9; P < 0.001). After controlling for other potential confounders including age, body mass index, tobacco use, and American Society of Anesthesiologists score, an SSI was 3.8 times more likely to develop in patients colonized with S aureus (OR, 3.8; P = 0.0025). The THA and spine colonized patients trended toward higher risk in both unadjusted and adjusted models; however, the results were not statistically significant. DISCUSSION: The results of our study suggest that decolonization may not be fully protective against SSI. The risk of infection after decolonization is not lowered to the baseline of a noncolonized patient. LEVEL OF EVIDENCE: Level IV.

BACKGROUND: Hospital readmission after total joint arthroplasty accounts for substantial resource consumption. Depression has been shown to impact postsurgical outcomes. We therefore aimed to study the association of depression with risk of readmission after total joint arthroplasty. METHODS: Retrospective cohort data from the population-based California Healthcare Cost and Utilization Project database from 2007 to 2010 were analyzed using multivariable logistic regression to predict odds of 90-day readmission after hospital discharge for primary total knee arthroplasty (TKA, n = 132,422) or total hip arthroplasty (THA, n = 65,071) arthroplasty in adults ages 50+ years. We included the primary exposure of depression and controlled for age, sex, race/ethnicity, Medicaid insurance, comorbidities, and admission year. RESULTS: Overall 90-day readmission rates were approximately 8% for TKA and THA. Even after controlling for other chronic conditions and nonmodifiable covariates, we found depression predicted higher likelihood of readmission. The odds of readmission for subjects with depression were 21%-24% higher overall (odds ratio for TKA: 1.21, 95% confidence interval: 1.13-1.29; odds ratio for THR: 1.24, 95% confidence interval: 1.13-1.35; P < .001). Subjects with surgery in earlier years were also more likely to be readmitted (P < .01). CONCLUSION: Depression is associated with a significantly higher risk of readmission after THA and TKA. Hospital readmissions must be minimized to improve care quality, while making these procedures fiscally feasible. Promoting care coordination across disciplines for management of nonorthopedic comorbidities before surgery, particularly in higher risk patients with depression, could optimize orthopedic surgery outcomes, patient well-being, and costs of care. Therefore, every effort to address depression before surgery is warranted.

We identified 168,247 total hip and total knee arthroplasties performed in New York State between 2010 and 2012 to examine the evidence for increased geographical and institutional centralization of these procedures. We measured the increased growth of high volume institutions as compared to lower volume hospitals in New York State. We found a high proportion of total arthroplasties already performed in the dozen biggest hospitals in New York back in 2010 and a significant higher growth of these high volume, "centers of excellence," hospitals when compared to low volume hospitals.

STUDY DESIGN: Retrospective review of an administrative database. OBJECTIVE: To observe New York statewide trends in lumbar spine surgery and to compare utilization of fusion according to hospital size and patient population. SUMMARY OF BACKGROUND DATA: Over the last 30 years, studies have indicated increasing rates of spinal fusion procedures performed each year in the United States. There is no study investigating potential variability in this trend according to hospital volume. METHODS: New York Statewide Planning and Research Cooperative System(SPARCS) administrative data were used to identify 228,882 lumbar spine surgerypatients. New York State hospitals were categorized as low-, medium- or high-volume and descriptive statistics were used to determine trends in spinal fusion. RESULTS: The number of fusions per year increased 55% from 2005-2014. The ratio of fusion to non-fusion surgery increased from 0.88 to 2.67 at high-, from 0.84 to 2.30 at medium- and from 0.66 to 1.52 at low-volume hospitals. In 2014, 22% of spine surgery patients at low-volume hospitals were either African American or Hispanic compared to 12% and 14% at high- and medium-volume hospitals, respectively. At high volume hospitals, 33% of patients were privately insured and 3% had Medicare compared to 30% and 6% at low-volume hospitals. CONCLUSIONS: The annual number of lumbar spinal fusions continues to increase, especially at high- and medium-volume hospitals. The percentage of patients treated surgically for lumbar spinal stenosis (LSS) who undergo fusion ranges from 53.2%-66.4% depending on hospital volume. Individual surgeon opinion, patient disease characteristics, and socioeconomic factors may affect surgical decision-making. Caucasians and private insurance patients most often receive care at high-volume hospitals. Minorities and patients with Medicaid are over-represented at low-volume centers where fusions are less often performed. Accessibility to care at high-volume centers remains a major concern for these vulnerable populations. LEVEL OF EVIDENCE: 3.

BACKGROUND: Computed tomography pulmonary angiography (CTA) is the gold standard for diagnosing pulmonary embolism (PE) but involves radiation and iodinated contrast exposure. Of orthopedic patients evaluated for PE, a minority have a positive CTA study. Herein, we evaluate end tidal carbon dioxide (ETCO2) as a method to identify patients at low risk for PE and may not require a CTA. We hypothesize that ETCO2 will be useful for predicting the absence of PE in postoperative orthopedic patients. METHODS: In this prospective study, all patients older than 18 years who were admitted for orthopedic surgery and who had a CTA performed for PE were eligible. These patients underwent an ETCO2 measurement. Patients were determined to have PE if they had a positive PE-protocol CT. RESULTS: Between May 2014 and April 2015, 121 patients met the inclusion criteria for the study. Of these patients, 84 had a negative CTA examination, 25 had a positive examination, and 12 had a nondiagnostic examination. We found a statistically significant difference (P = .03) when comparing the average ETCO2 values for the positive and negative CTA groups. An ETCO2 cutoff value of 43 mm Hg was 100% sensitive with a negative predictive value of 100% for absence of PE on CTA. CONCLUSION: This study demonstrates a significant difference in ETCO2 measurements between postoperative orthopedic patients with and without CTA-detected PE. A cutoff value of >43 mm Hg may be useful in excluding patients from undergoing CTA.

In 2015, the Centers for Medicare & Medicaid Services (CMS) began a mandatory bundling initiative to cover all services for hip and knee replacements. Broader expansion of alternative payment and delivery models has recently been introduced in the private sector. Bundled payments incentivize providers to appropriately reduce spending without compromising quality of care. Establishing market size, competitive pricing, and care coordination are integral to ensure the viability of a bundled payment model. The purpose of this study is to address key considerations for providers who plan to create an effective bundle in the private sector.

BACKGROUND: The Bundled Payment for Care Improvement (BPCI) Initiative is a Centers for Medicare and Medicaid Services program designed to promote coordinated and efficient care. This study seeks to report costs of readmissions within a 90-day episode of care for BPCI Initiative patients receiving total knee arthroplasty (TKA) or total hip arthroplasty (THA). METHODS: From January 2013 through December 2013, 1 urban, tertiary, academic orthopedic hospital admitted 664 patients undergoing either primary TKA or THA through the BPCI Initiative. All patients readmitted to our hospital or an outside hospital within 90-days from the index episode were identified. The diagnosis and cost for each readmission were analyzed. RESULTS: Eighty readmissions in 69 of 664 patients (10%) were identified within 90-days. There were 53 readmissions (45 patients) after THA and 27 readmissions (24 patients) after TKA. Surgical complications accounted for 54% of THA readmissions and 44% of TKA readmissions. These complications had an average cost of $36,038 (range, $6375-$60,137) for THA and $38,953 (range, $4790-$104,794) for TKA. Eliminating the TKA outlier of greater than $100,000 yields an average cost of $27,979. Medical complications of THA and TKA had an average cost of $22,775 (range, $5678-$82,940) for THA and $24,183 (range, $3306-$186,069) for TKA. Eliminating the TKA outlier of greater than $100,000 yields an average cost of $11,682. CONCLUSION: Hospital readmissions after THA and TKA are common and costly. Identifying the causes for readmission and assessing the cost will guide quality improvement efforts.

BACKGROUND: Venous thromboembolism (VTE) is a major concern after total joint arthroplasty (TJA). We evaluated a risk-stratified prophylaxis protocol for patients undergoing TJA. METHODS: A total of 2611 TJA patients were retrospectively studied. Patients treated with an aggressive VTE chemoprophylaxis protocol were compared with patients treated with a risk-stratified protocol utilizing aspirin and sequential pneumatic compression devices (SPCDs) for standard-risk patients and targeted anticoagulation for high-risk patients. RESULTS: We found equivalence in terms of VTE prevention between the 2 cohorts. There was a decrease in adverse events and readmissions among the risk-stratified cohort, although this did not reach statistical significance. A statistically significant reduction in costs (P < .001) was experienced with the use of aspirin/SPCDs compared with aggressive anticoagulation agents within the risk-stratified cohort. CONCLUSION: The use of aspirin/SPCDs in a risk-stratified TJA population is a safe and cost-effective method of VTE prophylaxis.

Introduction/objectives: Individuals co-infected with both HCV) and HIV represent a unique and growing population of patients undergoing orthopaedic surgical procedures. Data regarding complications for HCV monoinfection or HIV monoinfection is robust, but there exists a paucity of data regarding coinfected individuals. Methods: State-wide database was used to identify patients undergoing THA between 2010-2014. Patients were stratified into 4 groups based upon HCV/HIV status: healthy controls without disease, HCV monoinfection, HIV monoinfection, and co-infection. Differences regarding hospital LOS (days), total charges ($USD), discharge disposition, in-hospital complications, in-hospital mortality, and hospital readmission were calculated. Results: 80,722 patients underwent THA between 2010-2014. 98.55% had neither HCV nor HIV, 0.66% had HCV, 0.66% HIV and 0.13% were coinfected with both HCV and HIV. Co-infected patients were more likely to be younger, male, insured by Medicaid, history of AVN and be homeless. Additionally, co-infected patients had the highest rates of alcohol abuse, drug abuse, tobacco, and high rates of psychiatric disorders, including depression. HCV and HIV co-infection was an independent risk factor for increased LOS (p<0.001), total hospital charges in the 90th percentile (p<0.001), having 2 or more in-hospital complications (p<0.001), and 90-day readmission rates (p<0.001). Conclusions: As the prevalence of HCV and HIV co-infectivity continues to increase, surgeons will encounter a greater number of these patients. Awareness of the demographic and socioeconomic factors leading to increased complications after THA will allow physicians to consider interventions to improve patient health status in order to optimize outcomes and reduce costs