Faculty Bibliography

BACKGROUND: The most commonly used postacute care facility after total joint arthroplasty is a skilled nursing facility (SNF). However, little is known regarding the role of physical therapy achievements and insurance status on the decision to discharge from an SNF. In this study, we aim to compare functional outcomes and length of stay (LOS) at an SNF among patients with Medicare vs private health coverage. METHODS: We retrospectively collected physical therapy data for 114 patients who attended an SNF following acute hospitalization for total joint arthroplasty. Medicare beneficiaries were compared with patients covered by Managed Care (MC) policies (health maintenance organization [HMO] and preferred provider organization [PPO]) using several SNF discharge outcomes, including LOS, distance ambulated, and functional independence in gait, transfers, and bed mobility. RESULTS: LOS at the SNF was significantly longer for Medicare patients (Medicare: 24 +/- 22 days, MC: 12 +/- 7 days, P = .007). After adjusting for LOS and covariates, MC patients had significantly greater achievements in all functional outcomes measured. In a study subanalysis, Medicare patients were found to achieve similar functional outcomes by SNF day 14 as MC patients achieved by their day of discharge on approximately day 12. Yet, the Medicare group was not discharged until several days later. CONCLUSION: Medicare status is associated with poor functional outcomes, long LOS, and slow progress in the SNF. Our results suggest that insurance reimbursement may be a primary factor in the decision to discharge, rather than the achievement of functional milestones.

Acute blood loss anemia following total joint arthroplasty procedures puts patients at risk for multiple perioperative complications. Preventing symptomatic anemia in the arthroplasty patient population is specifically important because these patients are often at greater risk for myocardial ischemia due to medical comorbidities, and because it delays progression with physical therapy. In addition to maintaining hemostasis with meticulous surgical technique, several techniques have been developed to help surgeons minimize blood loss. Fibrin sprays, antifibrinolytics such as tranexamic acid, hypotensive anesthesia, bipolar sealers, reinfusion drains, and specific techniques for arthrotomy closure are several strategies that have become part of a multimodal approach to minimize blood loss and reduce transfusion requirement associated with total joint arthroplasty. Currently, published evidence most supports the routine use of tranexamic acid and hypotensive anesthesia in standard, primary hip and knee arthroplasty, but specific adjunctive strategies may be considered when warranted by the patient's clinical condition or surgical procedure.

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.

OBJECTIVE: To test whether use of a personalized report card, Nursing Home Compare Plus (NHCPlus), embedded in a reengineered discharge process, can lead to better outcomes than the usual discharge process from hospitals to nursing homes. DATA SOURCES/SETTING: Primary data collected in the Departments of Medicine and Surgery at a University Medical Center between March 2014 and August 2015. STUDY DESIGN: A randomized controlled trial in which patients in the intervention group were given NHCPlus. Participants included 225 patients or their family members/surrogates. DATA COLLECTION: Key strokes of NHCPlus users were recorded to obtain information about usage. Users were surveyed about usability and satisfaction with NHCPlus. All participants were surveyed at discharge from the hospital. Survey data were merged with medical records. PRINCIPAL FINDINGS: About 85 percent of users indicated satisfaction with NHCPlus. Compared to controls, intervention patients were more satisfied with the choice process (by 40 percent of the standard deviation p < .01), more likely to go to higher ranked five-star nursing homes (OR = 1.8, p < .05), traveled to further nursing homes (IRR = 1.27, p < .10), and had shorter hospital stays (IRR = 0.84, p < .05). CONCLUSIONS: Personalizing report cards and reengineering the discharge process may improve quality and may lower costs compared to the usual discharge process.

Patient-reported outcomes (PROs) are essential to assessing the effectiveness of care, and many general-health and disease-specific PROs have been developed. Until recently, data were collected predominantly with pen-and-paper questionnaires. Now, though, there is a potential role for electronic medical records in data collection. In this study, patients were randomly assigned to complete either tablet or paper questionnaires. They were surveyed on patient demographics, patterns of electronic device use, general-health and disease-specific PROs, and satisfaction. The primary outcome measure was survey completion rate. Secondary outcome measures were total time for completion, number of questions left unanswered on incomplete surveys, patient satisfaction, and survey preferences. The study included 483 patients (258 in tablet group, 225 in paper group), and the overall completion rate was 84.4%. There was no significant difference in PRO completion between the tablet and paper groups. Time to completion did not differ between the groups, but their satisfaction rates were similar. However, more paper group patients reported a preference for a tablet survey. Advantages of digital data collection include simple and reliable data storage, ability to improve completion rates by requiring patients to answer all questions, and development of interface adaptations to accommodate patients with handicaps. Given our data and these theoretical benefits, we recommend using tablet data collection systems for PROs.

Given the steady increase in the number of primary and revision total knee arthroplasties (TKAs) performed in the United States, we wanted to determine if an evidence-based TKA perioperative surgical home could close the perioperative morbidity gap between primary and revision TKAs. We conducted a prospective cross-sectional cohort study comparing outcomes of patients who had primary TKA (n = 235) with outcomes of patients who had revision TKA (n = 50). We measured several perioperative outcomes: length of stay, discharge disposition, 30-day readmission rate, and 30-day reoperation rate. Mean length of stay was 2.55 days for primary TKA and 2.92 days for revision TKA (P = .061). Eighty (34%) of the 235 primary TKA patients and 21 (41%) of the 51 revision TKA patients were discharged to a subacute nursing facility (P = .123). One primary TKA patient (0.4%) and 2 revision TKA patients (4%) were readmitted within 30 days after surgery (P = .081). None of the primary TKAs and 2 (4%) of the revision TKAs underwent reoperation (P = .993). There was no difference in perioperative outcomes between the primary and revision TKA groups in our Total Joint Replacement Perioperative Surgical Home (TJR-PSH) cohort. Advances in multidisciplinary co-management of TKA patients are highlighted in the TJR-PSH. The similarity in primary and revision TKA outcomes has significant implications regarding costs and potential increased patient satisfaction.

INTRODUCTION: Patient-specific implants and instruments (PSI) have been used in both knee and shoulder replacements due to the perceived benefits of improved surgical accuracy and efficiency. The proposed benefits of using a PSI in total hip arthroplasty (THA) are numerous and include reduction of operative time and improved mechanical and anatomical alignment leading to increased implant longevity, increased stability, and clinical outcomes. We describe a novel patient-specific instrumentation and a surgical method that may improve directed resection of acetabular bone and accurate cup placement during THA. MATERIALS AND METHODS: In this cadaveric study, 14 acetabuli were used. Pre-operative CT or MRI scans were obtained as part of the acetabular jigs Bullseye Hip Replacement Instruments(R) (Bullseye Hip Replacement, LLC, Las Vegas, Nevada) protocol. Two senior hip surgeons performed all the operations in accordance to the PSI technique. Post-operative CT scans were obtained and acetabular cup orientation was measured by two independent radiologists. RESULTS: Fourteen acetabuli were implanted using the Bullseye Hip Replacement Instruments(R). Acetabular cup anteversion angle as measured on post-operative CT images averaged, for all 14 acetabuli, 15.50. Acetabular cup abduction/inclination angle as measured on post-operative CT images averaged 35.9 degrees . All implanted components' size/diameter matched the preoperative surgical planned implant size. CONCLUSION: The Bullseye Hip Replacement Instruments(R) show good reproducible acetabular cup placement in both anteversion and abduction angles, and accurate sizing of the acetabular component. .

OBJECTIVES: Acute pain in the postoperative period after total joint arthroplasty (TJA) has a significant effect on early rehabilitation, hospital length of stay, and the development of chronic pain. Consequently, efforts have been made to predict the occurrence of postoperative pain using preoperative and intraoperative factors. In this study, we tested the usefulness of preoperative pressure pain threshold (PPT) values in the prediction of three outcomes for patients who underwent TJA: visual analog scale pain scores, hospital length of stay, and opioid consumption. MATERIALS AND METHODS: Using a digital pressure algometer, we measured the preoperative PPT in 41 patients expected to undergo TJA at three different body sites: the first web space of the hand, the operative joint, and the contralateral joint. We correlated each PPT separately with postoperative visual analog scale pain scores, hospital length of stay, and opioid consumption. RESULTS: No significant correlation was found between preoperative PPT and the three postoperative outcomes. This finding held true when patients were subdivided by surgery type (total knee arthroplasty vs. total hip arthroplasty). There was no significant difference in PPT between the three body testing sites. DISCUSSION: This study failed to prove the usefulness of PPT in the prediction of acute postoperative pain, pain medication consumption, and length of stay. The pressure algometer has previously found a place in the assessment of pain in a variety of clinical settings, but its utility has not yet been demonstrated in patients undergoing TJA.