Faculty Bibliography

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.

AIMS/OBJECTIVE:non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. PATIENTS AND METHODS/METHODS:(13.3 to 57.6, sd 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. RESULTS:There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period. CONCLUSION/CONCLUSIONS:2019;101-B(6 Supple B):2-8.

Background/UNASSIGNED:Spine surgery is associated with significant intraoperative blood loss, often leading to transfusion. Patients who receive transfusions have an increased length of stay and risk of perioperative complications. To decrease the transfusion rate, we implemented an evidence-based institution-wide restrictive transfusion blood management guideline. The goal of this study is to describe the impact of this guideline on our spine surgery patients. Methods/UNASSIGNED:We analyzed the incidence of transfusion following 3709 single-institution, inpatient spine procedures before and after implementation of a revised blood transfusion protocol. The baseline period (1742 patients) from January 2014 to March 2015 was compared to the study period (1967 patients) of April 2015 to July 2016. One patient was excluded because of incomplete medical records. The revised protocol included establishing a postoperative blood transfusion trigger at hemoglobin < 7g/dL, instituting a computerized provider order entry, and appointing a physician champion to monitor and report progress. Results/UNASSIGNED: = .01). There was no significant difference in total hospital costs following protocol implementation. Conclusions/UNASSIGNED:Implementation of a restrictive transfusion protocol through use of a computerized provider order entry and a physician champion to oversee clinician compliance led to a 40.1% reduction in blood transfusion following spine surgery. Behavior changes were visible with a 40.7% increase in hemoglobin documentation before transfusion, and patients benefited from a reduction in length of stay and postsurgical infection rate. Future study is encouraged to understand the long-term impact of this intervention and its role in hospital expenditure.

BACKGROUND:The study assesses whether Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores were influenced by hospital length of stay (LOS) and discharge disposition. METHODS:HCAHPS scores from 5,682 orthopaedic patients were collected over a 4-year period. Statistical analyses were run to identify associations between Top-Box scores for each HCAHPS domain and LOS or discharge disposition (home versus rehabilitation facility). RESULTS:Decreased LOS was associated with increased HCAHPS Top-Box scores for every Top-Box domain except for Discharge composite (P ≤ 0.001 to 0.011). Discharge to home was associated with increased HCAHPS scores for four Top-Box domains (P ≤ 0.001 to 0.009). DISCUSSION/CONCLUSIONS:Shorter LOS and discharge to home after orthopaedic surgery are associated with better HCAHPS scores. Earlier discharge leads to an improved patient-reported experience and can increase reimbursements. Expedient, appropriate discharge of hospitalized orthopaedic patients should be a treatment goal after orthopaedic surgery.

BACKGROUND:Private hospital rooms have a number of potential advantages compared to shared rooms, including reduced noise and increased control over the hospital environment. However, the association of room type with patient experience metrics in total joint arthroplasty (TJA) patients is currently unclear. METHODS:For private versus shared rooms, we compared our institutional Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in patients who underwent primary TJA over a 2-year period. Regression model odds ratios (ORs) were adjusted for surgeon, date of surgery, and length of stay. RESULTS:Patients in private rooms were more likely to report a top-box score for overall hospital rating (85.6% vs 79.4%, OR = 1.53, P = .011), hospital recommendation (89.3% vs 83.0%, OR = 1.78, P = .002), call button help (76.0% vs 68.7%, OR = 1.40, P = .028), and quietness (70.4% vs 59.0%, OR = 1.78, P < .001). There were no significant differences on surgeon metrics including listening (P = .225), explanations (P = .066), or treatment with courtesy and respect (P = .396). CONCLUSION/CONCLUSIONS:For patients undergoing TJA, private hospital rooms were associated with superior performance on patient experience metrics. This association appears specific for global and hospital-related metrics, with little impact on surgeon evaluations. With the utilization of HCAHPS data in value-based initiatives, placement of TJA patients in private rooms may lead to increased reimbursement and higher hospital rankings. LEVEL OF EVIDENCE/METHODS:Level III, retrospective cohort.

BACKGROUND:Routine immediate postoperative laboratory studies, including metabolic panels and hematologic profiles, are commonly ordered after arthroplasty procedures. However, their values only occasionally influence management. This study investigated the clinical utility and value of these tests. METHODS:A large retrospective cohort study of 18,935 patients spanning a 6-year period from 2008 to 2013 from a single high-volume institution was evaluated. Only immediate postoperative labs drawn on postoperative day 0 in the recovery room were included in the study. Complete blood counts (CBC) and basic metabolic panels (BMP) were reviewed, and ranges of abnormal were set for each lab test based on values significant enough to impact patient management. Cost effectiveness calculations were made based on current cost of the laboratory tests. RESULTS:Actionably low hemoglobin values ( < 8 g/dL) were found in 1.44% of the overall cohort. Unilateral primary total knee arthroplasty was associated with the fewest hemoglobin abnormalities at 0.59%. Primary unilateral total hip arthroplasty was associated with abnormal hemoglobin values in 1.81% of cases. Significant electrolyte abnormalities were far less common, with hyperkalemia (> 6.5 mEq/L) in 0.19%, hyponatremia ( < 120 mEq/L) in 0.01% and elevated creatinine (> 2.0 mg/dL) was found in 0.25%. Hemoglobin values were calculated at a cost of $1,710 to detect a single significantly abnormal result. The cost to detect a single actionably abnormal BMP value was $1,000. CONCLUSIONS:Routine immediate postoperative laboratory tests represent a high institutional cost and are seldom abnormal enough to warrant a change in patient management. The routine use of these tests can likely be safely eliminated in uncomplicated primary unilateral arthroplasty procedures.

INTRODUCTION/BACKGROUND:Hip and knee arthroplasty are high volume, clinically successful, but costly orthopedic surgical procedures. There is significant variation in volume, outcomes, and cost at various hospitals. METHODS:Using the Statewide Planning and Research Cooperative System (SPARCS) database to determine readmission rates and the New York State Department of Health (NYSDoH) hospital cost transparency database to obtain costs, we reviewed this data for hip and knee replacements to determine if there was a relationship between volume of procedures performed and cost or readmission rates. RESULTS:The readmission rate increased with increasing cost for facilities performing total knee arthroplasty (p = 0.02). Readmission rate did not change significantly with volume of procedures performed. Similarly, the readmission rate increased with increasing cost for facilities performing total hip arthroplasty but did not change significantly with respect to volume (p < 0.01). CONCLUSION/CONCLUSIONS:Spending more money to perform total hip and knee arthroplasty in New York State does not ensure lower readmission rates. Readmission rates vary independent of volume of procedures performed. Total hip and knee arthroplasty are two of the most successful and commonly performed orthopedic surgical procedures. Outcome investigations demonstrate reliable pain relief and consistently good or excellent functional outcomes.1-3 However, there is significant variability in both cost and quality of these procedures, resulting in a wide difference in their value. Porter defines value as outcomes divided by cost.4 One metric that reflects both the cost as well as the quality of care is the unplanned readmission rate. Whether readmission occurs as a result of thromboembolic disease, surgical site infection, or cardiopulmonary complications in the postoperative period, it represents a deterioration of outcome at a significant cost burden to the treating institution. The New York State Department of Health's Statewide Planning and Research Cooperative System (SPARCS) database was established in 1979. Licensed hospitals in the state are mandated to report data on all discharges, including inpatient and outpatient surgery procedures and emergency department admissions.5 On December 5, 2013, the New York State Department of Health made hospital-specific average costs for over 300 diagnosis-related groups (DRGs) available publicly on its website.6 Among the selected DRGs were total hip (301) and total knee (302) arthroplasty. The purpose of this study was to determine if there was a relationship between quality (as indicated by readmission rate) and either volume of procedures performed or cost of performing those procedures.

STUDY DESIGN/METHODS:Retrospective analysis of Medicare claims and procedure details from a single institution participation in the Bundled Payments for Care Improvement (BPCI) program. OBJECTIVE:To analyze the effects of the BPCI program on patient outcome metrics and cost data. SUMMARY OF BACKGROUND DATA/BACKGROUND:The BPCI program was designed to improve the value of care provided to patients, but the financial consequences of this system remain largely unknown. We present two years of data from participation in the lumbar spine fusion bundle at a large, urban, academic institution. METHODS:In 2013 and 2014, all Medicare patients undergoing lumbar spine fusions for DGR 459 (spinal fusion except cervical with MCC) and 460 (without MCC) at our institution were enrolled in the BPCI program. We compared the BPCI cohort to a baseline cohort of patients under the same DRGs from 2009 to 2012 from which the target price was established. RESULTS:350 patients were enrolled into the BPCI program, while the baseline group contained 518 patients. When compared to the baseline cohort, length of stay decreased (4.58 +/- 2.51 vs 5.13 +/- 3.75; p = 0.009), readmission rate was unchanged, and discharges with HHA increased. Nonetheless, we were unable to effect an episode-based cost savings ($52,655 +/- 27,028 vs $48,913 +/- 24,764). In the larger DRG 460 group, total payments increased in the BPCI group ($51,105 +/- 26,347 vs $45,934 +/- 19,638, p = 0.001). Operative data demonstrated a more complex patient mix in the BPCI cohort. The use of interbody fusions increased from 2% to 16% (p < 0.001), and the percentage of complex spines increased from 23% to 45% (p < 0.001). CONCLUSIONS:Increased case complexity was responsible for increasing costs relative to the negotiated baseline target price. This payment system may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and technologies. LEVEL OF EVIDENCE/METHODS:3.