Faculty Bibliography

BACKGROUND: In January 2013, a large, tertiary, urban academic medical center began participation in the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty, a program implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011. Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 were included. We participated in BPCI Model 2, by which an episode of care includes the inpatient and all post-acute care costs through 90 days following discharge. The goal for this initiative is to improve patient care and quality through a patient-centered approach with increased care coordination supported through payment innovation. METHODS: Length of stay (LOS), readmissions, discharge disposition, and cost per episode of care were analyzed for year 3 compared with year 1 of the initiative. Multiple programs were implemented after the first year to improve performance metrics: a surgeon-directed preoperative risk-factor optimization program, enhanced care coordination and home services, a change in venous thromboembolic disease (VTED) prophylaxis to a risk-stratified protocol, infection-prevention measures, a continued emphasis on discharge to home rather than to an inpatient facility, and a quality-dependent gain-sharing program among surgeons. RESULTS: There were 721 Medicare primary total joint arthroplasty patients in year 1 and 785 in year 3; their data were compared. The average hospital LOS decreased from 3.58 to 2.96 days. The rate of discharge to an inpatient facility decreased from 44% to 28%. The 30-day all-cause readmission rate decreased from 7% to 5%; the 60-day all-cause readmission rate decreased from 11% to 6%; and the 90-day all-cause readmission rate decreased from 13% to 8%. The average 90-day cost per episode decreased by 20%. CONCLUSIONS: Mid-term results from the implementation of Medicare BPCI Model 2 for primary total joint arthroplasty demonstrated decreased LOS, decreased discharges to inpatient facilities, decreased readmissions, and decreased cost of the episode of care in year 3 compared with year 1, resulting in increased value to all stakeholders involved in this initiative and suggesting that continued improvement over initial gains is possible.

BACKGROUND: The post-acute care strategies after lower extremity total joint arthroplasty including the use of post-acute rehabilitation centers and home therapy services are associated with different costs. Providers in bundled payment programs are incentivized to use the most cost-effective strategies. METHODS: We used decision analysis to examine the impact of extending the inpatient hospital stay to avoid discharge of patients to a post-acute rehabilitation facility. RESULTS: The results of this decision analysis show that extended acute hospital care for up to 5.2 extra days to allow for home discharge, rather than discharge to a post-acute inpatient facility can be financially preferable, provided quality is not negatively impacted. CONCLUSION: The data demonstrate that because the cost of additional acute care hospital days is relatively small and because the cost of an extended post-acute inpatient rehabilitation facility is high, keeping patients in the acute facility for a few extra days and then discharging them directly to home may result in an overall lower cost than discharge after a shorter hospital stay to an expensive post-acute facility. However, this approach will have challenges, and future studies are needed to evaluate this change in strategy.

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.