Faculty Bibliography

BACKGROUND:Workers Compensation claims have been previously associated with inferior clinical outcomes. However, variation in inpatient stays for orthopedic trauma injuries according to insurance type has not been previously examined. METHODS:We investigated the differences according to insurance for tibial shaft fractures in regard to length of stay and disposition. Using the New York SPARCS database, we identified 1,856 adult non-elderly patients with an isolated tibial shaft fracture who underwent surgery. Patients were stratified by insurance type, including private, Medicaid, Workers Compensation, and no-fault, which covers medical expenses related to automobile or pedestrian accidents. RESULTS:Compared to private insurance (mean: 2.7 days), length of stay was longer for no-fault (mean: 3.9 days; adjusted difference +33%, p < 0.001) and Medicaid (mean: 3.5 days; adjusted difference +22%, p < 0.001), but not significantly different for Workers Compensation (mean: 3.5 days; adjusted difference +4%, p = 0.474). Compared to private insurance (rate: 3.5%), disposition to a facility was significantly higher for no-fault (rate: 10.1%; adjusted odds ratio [OR] = 3.3, p < 0.001) and Medicaid (rate: 7.6%; OR = 2.2, p = 0.003), but was not significantly different for Workers Compensation (rate: 6.3%; OR = 1.8, p = 0.129). CONCLUSIONS:Patients with no-fault insurance, but not Workers Compensation, are subject to longer hospital stays and are more likely to be discharged to a facility following operative fixation of an isolated tibial shaft fracture. These findings suggest that financial, social, and legal factors influence medical care for patients involved in automobile accidents with no-fault insurance.

BACKGROUND CONTEXT: As the opioid crisis has gained national attention, there has been an increasing effort to decrease opioid usage. Simultaneously, patient satisfaction is a crucial metric in the American health care system, and has been closely linked to effective pain management in surgical patients. PURPOSE: Examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A total of 1,729 patients undergoing any spine surgery. OUTCOME MEASURES: Rates of non-opioid pain medication prescriptions during hospitalization as part of a multimodal analgesia regimen, morphine milligram equivalents (MME) of opioids used during hospitalization, Press Ganey Satisfaction Survey data.
METHOD(S): Patients >=18yo undergoing spine surgery between 6/25/2017-6/30/2018 at a single institution by spine surgeons performing >=20 surgeries/quarter and who had medication data during hospitalization available included. Additional data collected included physician and procedure type. All data analyzed by quarter. Chi-squared test to compare percentages and ANOVA to compare means across quarters. Multivariate regression used to compare procedure-specific trends, controlling for age, revision and level of pain. Significance set at p<0.05.
RESULT(S): A total of 1,759 patients were included, 427 in Quarter 1 (Q1), 439 in Q2, 453 in Q3 and 440 in Q4. Mean total MME per patient hospitalization was 574.46, no significant difference between quarters (p=0.116). Mean MME/day per patient decreased between quarters (p=0.048), with highest mean 91.84 in Q2 and lowest 77.50 in Q4. From Q1 to Q4, three physicians had decreased mean MME/day (75.47->50.92, p=0.023; 115.70->46.05, p=0.013; 92.89->69.53, p=0.42, respectively) and two physicians had decreased total MME (815.88->243.15, p=0.004; 706.79->451.72, p=0.014, respectively). MME/day decreased (74.78->52.37, p=0.046) for discectomy cases. Controlling for age, revision and level of pain, total MME decreased for discectomies (p=0.006). Among all procedures, acetaminophen, NSAID and steroid prescription rates increased (9.13%->17.05%, p=0.001; 6.32%->9.77%, p=0.048; 9.13%->17.05%, p=0.001, respectively). This was also the case in fusion patients specifically (9.09%->17.99%, p=0.002; 2.77%->5.76%, p=0.024; 9.09%->17.99%, p=0.002, respectively). NSAID prescription in laminectomy patients also increased (3.23%->4.89%, p=0.041). Concurrently, benzodiazepine and GABA analog prescriptions decreased among all procedures (19.20%->10.68%, p<0.001; 9.84%->4.77%, p=0.025, respectively). Benzodiazepine prescriptions in fusion patients also decreased (24.51%->12.23%, p<0.001). No significant differences between quarters for mean pain ratings (p=0.521). Also no differences between quarters for responses to questions from Press Ganey Satisfaction Survey regarding how often staff talk about pain (p=0.164), whether staff talk about pain treatment (p=0.595) or recommending the hospital (p=0.096). This was also the case for top box ratings for the same questions (p=0.381, 0.837, 0.610, respectively). No significant differences between quarters for responses in all other patient satisfaction questions (range p=0.359-0.988) or their top box ratings (range p=0.359-0.988).
CONCLUSION(S): Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, while satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use amongst providers, and suggest the ability to do so without impacting overall satisfaction rates. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
Copyright

In 2012, the Centers for Disease Control and Prevention issued a recommendation for hepatitis C screening of adults born between 1945-1965. Our institution incorporated birthcohort screening into its pre-admission testing program for elective orthopedic procedures on February 3, 2015. The goal of this study was to report the results and costs of pre-admission birth-cohort hepatitis C screening at our institution from February 3, 2015, to January 27, 2017. A total of 11,659 elective inpatient procedures were scheduled during this time and 97.8% of eligible patients were screened. Nine patients with active infection were identified, and four were successfully treated. Costs were calculated using time-driven activity-based costing. The total screening cost per successfully treated patient was $36,930.02. Since patients were not routinely screened at our institution before this intervention, our 97.8% screening capture rate demonstrates that pre-admission testing for elective procedures is a novel, yet effective and underutilized way, to engage "baby boomers" in screening.

BACKGROUND:Little is known about the factors that drive hospital-switching behavior of patients when they seek a second total joint arthroplasty (TJA) surgery. METHODS:We analyzed the population-based, all-payer California Healthcare Cost and Utilization Project (HCUP) data for a cohort undergoing sequential TJAs for osteoarthritis (N = 48,800) from 2006 to 2011, excluding TJA for fracture. We used multivariable logistic regression analysis to identify factors associated with returning to the same hospital for each surgery, including rural or urban, surgery sequence and timing, Deyo-Charlson comorbidity index, age, sex, race and ethnicity, and insurance. RESULTS:Overall, 15.1% of subjects (7,364/48,000) utilized a different hospital for their second surgery. Increasing years between TJAs was associated with decreasing odds of going to the same hospital for the second TJA (p < 0.05). Subjects switching from private insurance to Medicare between surgeries were much less likely to return to same hospital (OR: 0.53; 95% CI: 0.47-0.59), as were those with alternate-joint sequencing (e.g., hip-knee). Those with Medicaid were somewhat less likely to return for the second surgery (OR: 0.87; 95% CI: 0.75-1.01). Urban and rural residents were equally likely to return to the same hospital (p > 0.05). Increasing age was associated with increasing likelihood of returning to the same hospital [e.g., ages 75- 79, OR: 1.36 (95% CI: 1.19-1.56) and ages 80+, OR: 1.41 (95% CI: 1.22-1.63)]. CONCLUSION/CONCLUSIONS:Fifteen percent of patients switched hospitals for their second TJA within the 6-year study period. Those with Medicare or who had surgery on the alternate joint for second surgery were more likely to switch hospitals as were those who waited longer between surgeries and those living in a rural environment.

BACKGROUND:In total joint arthroplasty, variation in implant use can be driven by vendor relationships, surgeon preference, and technological advancements. Our institution developed a preferred single-vendor program for primary hip and knee arthroplasty. We hypothesized that this initiative would decrease implant costs without compromising performance on quality metrics. METHODS:The utilization of implants from the preferred vendor was evaluated for the first 12 months of the contract (September 1, 2017, to August 31, 2018; n = 4,246 cases) compared with the prior year (September 1, 2016, to August 31, 2017; n = 3,586 cases). Per-case implant costs were compared using means and independent-samples t tests. Performance on quality metrics, including 30-day readmission, 30-day surgical site infection (SSI), and length of stay (LOS), was compared using multivariable-adjusted regression models. RESULTS:The utilization of implants from the preferred vendor increased from 50% to 69% (p < 0.001), with greater use of knee implants than hip implants from the preferred vendor, although significant growth was seen for both (from 62% to 81% for knee, p < 0.001; and from 38% to 58% for hip, p < 0.001). Adoption of the preferred-vendor initiative was greatest among low-volume surgeons (from 22% to 87%; p < 0.001) and lowest among very high-volume surgeons (from 61% to 62%; p = 0.573). For cases in which implants from the preferred vendor were utilized, the mean cost per case decreased by 23% in the program's first year (p < 0.001), with an associated 11% decrease in the standard deviation. Among all cases, there were no significant changes with respect to 30-day readmission (p = 0.449) or SSI (p = 0.059), while mean LOS decreased in the program's first year (p < 0.001). CONCLUSIONS:The creation of a preferred single-vendor model for hip and knee arthroplasty implants led to significant cost savings and decreased cost variability within the program's first year. Higher-volume surgeons were less likely to modify their implant choice than were lower-volume surgeons. Despite the potential learning curve associated with changes in surgical implants, there was no difference in short-term quality metrics. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Core muscle injuries are being diagnosed with increasing frequency in athletes. Knowledge of the anatomy is key to understanding the pathology. Notably, the origin on the pubis of the majority of adductor long muscles is via direct insertion of the muscle to the bone and not via a tendon, thus making direct repair difficult.

BACKGROUND:It is well recognized that unplanned readmissions following total joint arthroplasty (TJA) are more prevalent in patients with comorbidities. However, few investigators have delayed surgery and medically optimized patients prior to surgery. In its current form, the Perioperative Orthopedic Surgical Home (POSH) is a surgeon-led screening and optimization initiative targeting 8 common modifiable comorbidities. METHODS:A total of 4188 patients who underwent TJA between January 2014 and December 2016 were retrospectively screened by the Readmission Risk Assessment tool (RRAT) score. one thousand one hundred and ninety four subjects had a preoperative RRAT score ≥3 and were eligible for inclusion. Patients were then separated into 2 cohorts based on whether they were enrolled into the POSH initiative (POSH; n = 216) or continued with surgery (non-POSH; n = 978) despite their risk. RESULTS:Since the implementation of the POSH initiative, patients with RRAT scores ranging from 3 to 5 have experienced lower 30-day (1.6% vs 5.3%, P = .03) and 90-day (3.2% vs 7.4%, P < .05) readmission rates when compared to the non-POSH cohort. Only 15.3% of medically optimized patients enrolled in the POSH initiative were discharged to a post-acute care facility, whereas 23.4% of non-POSH patients were discharged to a post-acute care facility (P = .01). There were no differences in length of stay and infection rates between the 2 cohorts. Moreover, 90-day episode-of-care costs were 14.9% greater among non-POSH Medicare TJA recipients and 32.6% higher if a readmission occurred. CONCLUSION/CONCLUSIONS:The identification and medical optimization of comorbidities prior to surgical intervention may enhance the value of care TJA candidates receive. A standardized multidisciplinary approach to the medical optimization of high-risk TJA candidates may improve patient engagement and perioperative outcomes, while reducing cost associated with TJA. LEVEL OF EVIDENCE/METHODS:Level III, Retrospective Cohort Study.

INTRODUCTION/BACKGROUND:Magnet Recognition is the highest distinction a healthcare organization can receive for excellence in nursing. Although Magnet status is generally associated with superior clinical outcomes and patient satisfaction, its association with performance on nationwide quality metrics is currently unknown. METHODS:Within a propensity score-matched cohort, we compared performance on the Hospital-Acquired Condition Reduction Program (HACRP), Hospital Value-Based Purchasing (VBP), and Hospital Readmissions Reduction Program (RRP) initiatives. RESULTS:The mean HACRP total performance score was inferior at Magnet versus non-Magnet hospitals (p < .001), and HACRP penalties were more likely to be levied against Magnet hospitals (p = .003). There was no significant difference according to Magnet status for VBP penalties after correcting for multiple comparisons (p = .049). There were no significant difference in RRP penalties according to Magnet status (p = .999). CONCLUSIONS:Magnet hospitals performed worse on a number of hospitalwide quality metrics tied to reimbursement by the Centers for Medicare and Medicaid Service. Although Magnet hospitals are known for superior nursing care and organizational support for safety and quality improvement, this is not captured within these composite measures of quality, which can be influenced at many levels of care. These data underscore the need for comprehensive quality improvement across multiple domains of care outside of nursing. LEVEL OF EVIDENCE/METHODS:Level III, retrospective study.