Faculty Bibliography
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270
The Ethics of Telemedicine
PMID: 34081881
ISSN: 2328-5273
CID: 5295012
Complication Prevention and Cost Savings in Total Joint Arthroplasty. The Effect of Orthopedic Procedure Migration within Hospital Referral Regions in the United States
BACKGROUND:The shift to value based total joint arthroplasty (TJA) reimbursement strategies has led to an increased focus on quality and the avoidance of poor outcomes. As a result, there has been greater encouragement for patients to undergo joint replacements in high volume centers of excellence. In this study, we examined the potential complications avoided if TJA procedure volume was shifted from poor quality (high incidence) facilities to high quality (low incidence) facilities within Hospital Referral Regions (HRRs). METHODS:Using Medicare 100% claims data linked to the Dartmouth Atlas of Health Care, we examined the clinical and cost benefits of shifting TJA procedures from low performing hospital to high performing hospitals within HRRs. RESULTS:Across all HRRs, we identified 1,878 cases of deep infection and 3,393 annual readmissions in the Medicare population that could have potentially been avoided, resulting in a mean cost savings of $41 million and $62 million, respectively, solely due to shifting procedure location from lower third performing hospitals to the upper third performing hospitals. CONCLUSIONS:Our study demonstrates that the incidence of deep infection and all-cause readmission varies widely among and within HRRs. Further, the potential reallocation of joint procedures from low quality facilities to high quality Centers of Excellence within an HRR could result in over $103 million in annual savings related to mitigated deep infections and readmissions.
PMID: 34081884
ISSN: 2328-5273
CID: 4891872
The Use and Acceptance of Telemedicine in Orthopedic Surgery During the COVID-19 Pandemic
PMID: 32931363
ISSN: 1556-3669
CID: 4592902
The Effect of Medicare's Bundled Payments for Care Initiative on Patient Risk Factors Prior to Total Knee Arthroplasty
BACKGROUND:Medicare's Bundled Payments for Care Initiative (BPCI) is a risk-sharing alternative payment model. There is a concern that BPCI providers may avoid operating on obese patients and active smokers to reduce costs. We sought to understand if increased focus on these patient factors has led to a change in patient demographics in Medicare-insured patients undergoing total knee arthroplasty (TKA). METHODS:. RESULTS:, there was no significant change. CONCLUSIONS:Despite concern that reimbursement payments could alter access to care for patients with certain risk factors, this study did not find a noticeable difference in the representation of patients with obesity and smoking status undergoing TKA following the installation of BPCI. LEVEL OF EVIDENCE/METHODS:III, retrospective observational analysis.
PMID: 33500204
ISSN: 1532-8406
CID: 4767182
A Preferred Vendor Model Reduces the Costs of Sports Medicine Surgery
PURPOSE/OBJECTIVE:The purpose of this study was to report on our institution's first year of experience with a preferred vendor program for implants and disposables for sports medicine surgery. METHODS:Cost and utilization data for implants and disposables were analyzed for knee and shoulder sports medicine surgeries performed during the 2-year period including the twelve months preceding the start of the contract (Contract Year 0 [CY0] and the first twelve months of the contract period (CY1). The costs of grafts and biological therapies were excluded. Utilization of the preferred vendor's products, operative time and per-case costs were compared between the two time periods and adjusted for patient factors and case mix. RESULTS:Utilization of the preferred vendor's shavers (0% to 94%, p<0.001) and radiofrequency ablation wands (0% to 91%, p<0.001) increased significantly in CY1 (N=5,068 cases) compared to CY0 (N=5,409 cases), with a small but significant increase in use of the preferred vendor's implants (64% to 67%, p=0.023). There was no significant difference in mean operative time between CY0 and CY1 (p=0.485). Mean total per-case implant and disposable costs decreased by 12% (p<0.001) in CY1 versus CY0. CONCLUSION/CONCLUSIONS:Our institution was able to reduce the costs of sports medicine surgery with the implementation of a preferred single vendor program for implants and disposables. This program had widespread surgeon adoption and did not have any detrimental effect on operating room efficiency.
PMID: 33249245
ISSN: 1526-3231
CID: 4693752
Low dose aspirin is effective in preventing venous thromboembolism in patients undergoing primary total knee arthroplasty
Introduction/UNASSIGNED:Venous thromboembolism (VTE) is a known complication after total knee arthroplasty (TKA) with well-established morbidity, mortality, and significant healthcare expenditure. However, no standard form of prophylaxis against VTE currently exists. Methods/UNASSIGNED:A retrospective review was performed identifying 12,866 TKA cases and post-operative VTE events using either 325 mg aspirin or 81 mg aspirin twice daily (BID). Results/UNASSIGNED:133 VTE cases were diagnosed of the 9413 TKA on 325 mg aspirin BID compared to 8 VTE cases out of 3453 TKA on 81 mg aspirin BID (1.41% vs. 0.23%, p < 0.001). Conclusion/UNASSIGNED:81 mg aspirin BID significantly improved post-operative VTE rates over 325 mg aspirin BID.
PMCID:7902281
PMID: 33679024
ISSN: 0972-978x
CID: 4808922
Short-term prediction of opioid prescribing patterns for orthopaedic surgical procedures: a machine learning framework
Overprescribing of opioids after surgical procedures can increase the risk of addiction in patients, and under prescribing can lead to poor quality of care. In this study, we propose a machine learning-based predictive framework to identify the varying effects of factors that are related to the opioid prescription amount after orthopaedic surgery. To predict the prescription classes, we train multiple classifiers combined with random and SMOTE over-sampling and weight-balancing techniques to cope with the imbalance state of the dataset. Our results show that the gradient boosting machines (XGB) with SMOTE achieve the highest classification accuracy. Our proposed analytical framework can be employed to assist and therefore, enable the surgeons to determine the timely changing effects of these variables.
SCOPUS:85099588238
ISSN: 2573-234x
CID: 4770092
Journal of the American Academy of Orthopaedic Surgeons. 2020:28(24):1041-1046.DOI: 10.5435/JAAOS-D-20-00050
Opioid Prescribing Patterns in Orthopaedic Surgery Patients: the Effect of New York State Regulations and Institutional Initiatives
BACKGROUND:The opioid epidemic in the United States is a public health crisis. As a result, regulatory agencies, including state governments, have enacted initiatives to decrease the use of opioids in the perioperative setting. The purpose of this study was to compare opioid utilization in orthopaedic surgery patients at discrete points after implementation of State regulatory and institution/physician-led initiatives to decrease opioid utilization in the perioperative period. METHODS:We reviewed the electronic medication orders for all patients who underwent orthopaedic surgery procedures between September 2015 and June 2018 at our urban academic medical center. The outcome measures were the number of patients who were prescribed opioid medications, duration of prescription (days), and average milligram morphine equivalents prescribed. Patients were divided into three time cohorts to assess the effect of the NY State (NYS) policy and institutional initiatives to decrease opioid utilization. RESULTS:A total of 20,483 patients met the inclusion criteria over all three time cohorts. After the initiation of the NYS 7-day supply legislation, there was a decrease in the average supply of opioids prescribed from 10.1 to 7.6 days and the average daily milligram morphine equivalent decreased from 67.9 to 56.7 mg (P < 0.0001). However, with the combination of physician education and surgeon-led institutional initiatives, the percentage of patients who were prescribed opioids decreased by over 10% (96% to 84%), with continued decrease in duration of prescription by 1.0 to 6.4 days (P < 0.0001). CONCLUSIONS:The addition of institution-led initiatives and education programs to previously established government-led prescription limits produced a substantial reduction in the amount of opioids prescribed to orthopaedic surgery patients in the perioperative period. Although mandatory limits set by the state government resulted in a decreased amount of opioid medications being prescribed per patient, it was only after the introduction of educational programs and institution- and physician-led programs that perioperative patient exposure to opioids decreased. LEVEL OF EVIDENCE/METHODS:Level III.
PMID: 32301820
ISSN: 1940-5480
CID: 4383842
Ethical Implications of Resuming Elective Orthopedic Surgery During the COVID-19 Pandemic
The COVID-19 pandemic has had unprecedented impact on the United States health care system. One of the consider-ations was the decision to halt elective orthopedic surgery to preserve consumption of scarce resources. However, as the number of COVID-19 cases decrease, there will be discus-sions regarding the modality of resuming elective orthopedic surgery. Ethical considerations will come to the forefront in terms of determining the best course of action, patient selection, resource rationing, and financial implications. These factors will be examined through the lens of the four tenets of bioethics, beneficence, maleficence, autonomy, and justice, to elucidate the best approach in ethically manag-ing elective orthopedic surgery during a global pandemic.
PMID: 33207142
ISSN: 2328-5273
CID: 4708192
Trends in Pain Medication Prescriptions and Satisfaction Scores in Spine Surgery Patients at a Single Institution
BACKGROUND:As the opioid crisis has gained national attention, there have been increasing efforts to decrease opioid usage. Simultaneously, patient satisfaction has been a crucial metric in the American health care system and has been closely linked to effective pain management in surgical patients. The purpose of this study was to examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients. METHODS:test of independence was used to compare percentages, and 1-way analysis of variance was used to compare means across quarters. RESULTS:value range, .359-.988). CONCLUSIONS:Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without affecting overall satisfaction rates. LEVEL OF EVIDENCE/METHODS:4. CLINICAL RELEVANCE/CONCLUSIONS:The opioid epidemic has highlighted the need to reduce opioid usage in orthopedic spine surgery. This study reviews the trends for inpatient management of post-op pain in orthopedic spine surgery patients in relation to patient satisfaction. There was a significant increase in non-opioid analgesic pain medications, and a reduction in opioids during the study period. During this time, patient satisfaction as measured by Press-Ganey surveys did not show a decrease. This demonstrates that treatment of post-operative pain in orthopedic spine surgery patients can be managed with less opioids, more multimodal analgesia, and patient satisfaction will not be affected.
PMID: 33560264
ISSN: 2211-4599
CID: 4779592
