Faculty Bibliography

BACKGROUND:Over the past decade, reimbursement models and target payments have been modified in an effort to decrease costs of revision total knee arthroplasty (rTKA) while maintaining the quality of care. The goal of this study was to investigate trends in revenue and costs associated with rTKA. METHODS:We retrospectively reviewed all patients who underwent rTKA between 2011 and 2021 at our institution. Patients were stratified into groups based on insurance coverage: Medicare, government-managed or Medicaid (GMM), or commercial insurance. Patient demographics were collected, as well as revenue, costs, and contribution margin (CM) of the inpatient episode. Changes over time as a percentage of 2011 numbers were analyzed. Linear regressions were used to determine trend significance. In the 10-year study period, 1,698 patients were identified with complete financial data. RESULTS:Overall total cost has increased significantly (P < .01). While revenues and CM for Medicare and Commercial patients remained steady between 2011 and 2021, CM for GMM patients decreased significantly (P = .01) to a low of 53.2% of the 2011 values. Since 2018, overall CM and revenues decreased significantly (P = .05, P = .01, respectively). CONCLUSION/CONCLUSIONS:While from 2011 to 2018 general revenues and CM were relatively steady, since 2018 they have decreased significantly to their lowest values in over a decade for GMM and commercial patients. This trend is concerning and may potentially lead to decreased access to care. Re-evaluation of reimbursement models for rTKA may be necessary to ensure the financial viability of this procedure and prevent issues with access to care. LEVEL OF EVIDENCE/METHODS:III.

INTRODUCTION/BACKGROUND:Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only (IPO) list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty (TJA) surgery. METHODS:We reviewed all patients who underwent TKA or THA after these procedures were removed from the IPO list. Patients were stratified into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-square tests. RESULTS:Among Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (p<0.001), though there was no significant difference between cohorts for TKA (p=0.501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (p<0.001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (p<0.001). CONCLUSION/CONCLUSIONS:Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at risk of losing access to care.

INTRODUCTION/BACKGROUND:Preoperative medical optimization is necessary for safe and efficient care of the orthopaedic trauma patient. To improve care quality and value, a preoperative matrix was created to more appropriately utilize subspecialty consultation and avoid unnecessary consults, testing, and operating room delays. Our study compares surgical variables before and after implementation of the matrix to assess its utility. METHODS:A retrospective review of all orthopaedic trauma cases 6 months before and after the use of the matrix (2/2021-8/2021) was conducted an urban, level one trauma centre in collaboration with internal medicine, cardiology, anaesthesia, and orthopaedics. Patients were separated into two cohorts based on use of the matrix during the initial orthopaedic consultation. Logistic regressions were performed to limit significant differences in comorbidities. Independent samples t-tests and Chi-squared tests were used to compare means and proportions, respectively, between the two cohorts. RESULTS:In total, 576 patients were included in this study (281 pre- and 295 post-matrix implementation). Use of the matrix resulted in no significant difference in time to OR, LOS, readmissions, or ER visits; however, it resulted in 18% fewer overall preoperative consults for general trauma, and 25% fewer pre-operative consults for hip fractures. Older patients were more likely to require a consult regardless of matrix use. When controlling for comorbidities, patients with renal disease were at higher risk for increased LOS. CONCLUSION/CONCLUSIONS:Use of an orthopaedic surgical matrix to predict preoperative subspecialty consultation is easy to implement and allows for better care utilization without a corresponding increase in complications and readmissions. Follow-up studies are needed to reassess the relationships between matrix use and a potential decrease in ER to OR time, and validate its use.

BACKGROUND:Deep surgical site infections (dSSI) following spinal laminectomy and fusion are serious complications associated with poor patient outcomes. The objective of this study is to investigate the monthly and seasonal variability of dSSI rates following common spinal surgeries to investigate the "July effect," which refers to the alleged increase in adverse health outcomes due to new hospital trainees at the beginning of the academic year. METHODS:We performed a retrospective analysis of patients who had a dSSI following laminectomy (without fusion) or spinal fusion (with or without laminectomy) at a single large urban academic medical center between January 2009 and August 2018. The change in dSSI rate over the entire study period was calculated. The monthly and seasonal variability of dSSI were assessed using a Poisson regression model to assess for the presence of the July effect. RESULTS:= 0.04 ). With July as the reference month, there was a significantly higher dSSI rate in April following spinal fusions. CONCLUSION/CONCLUSIONS:The overall decrease in dSSI rate over the study period is consistent with previous reports. The monthly analysis revealed no significant differences in either procedure, calling into question the July effect. CLINICAL RELEVANCE/CONCLUSIONS:This study is relevant to practicing spinal surgeons and can inform surgeons about seasonal data regarding dSSIs. LEVEL OF EVIDENCE: 3/METHODS/:

BACKGROUND:Handwritten consent forms for medical treatment are commonly used despite the associated risk of documentation errors. We performed an internal audit of handwritten surgical consent forms to assess the quality of consenting practices within the department of hand surgery at our orthopedic specialty hospital. METHODS:A sample of 1,800 charts was selected. Con- sents were assessed for procedure type, physician details, abbreviations, consistency, and legibility. RESULTS:A total of 1,309 charts met the inclusion crite- ria. Two hundred and eight consents contained at least one illegible word. The name of the consenting physician was not listed or illegible on 114 forms. Medical abbreviations were found on 1.8% of all included forms, and 19 consent forms contained a crossed-out word or correction. CONCLUSIONS:Although the majority of the handwrit- ten consent forms were complete, accurate, and legible, there were notable errors in the consenting process at our institution. Documentation errors have medical and ethical ramifications. Further research into consenting practices is necessary to improve the quality of consent forms and the process of informed consent.

BACKGROUND:Surgical site infections (SSIs) are a signifi- cant cause of morbidity and mortality following total joint arthroplasty (TJA). While many risk factors are known, the seasonal and temporal associations of SSI are less under- stood. Understanding the associations can help reduce SSI rates. METHODS:We tracked rates of deep surgical site infec- tions (dSSIs) following total hip arthroplasty (THA) at a single large urban academic medical center from January 2009 through August 2018. Using a Poisson regression, we determined the monthly and seasonal variability of dSSIs. We also calculated the change in dSSI rate over the entire 9.67-year study period. RESULTS:In total, 15,703 THA cases between January 2009 and August 2018 were analyzed. There was no signifi- cant difference in the dSSI rate following THA in fall, winter, or spring as compared to summer. Similarly, there was no significant difference in dSSIs in July as compared to other months of the year. The average rate of dSSIs following THA was 1.04 (SD, 0.90) per 100 patients. The dSSI rate following THA decreased over the study period (r = 0.93, 95% CI: 0.84-1.03) but did not reach statistical significance. CONCLUSION/CONCLUSIONS:This study demonstrated a non-significant, albeit decreasing, rate of dSSIs following THA over the study period. Contrary to previous reports, there was no difference in the dSSI rate in the summer months as compared to other seasons. The month of the year also does not appear to be a significant risk factor for SSIs, calling into question previous reports arguing for the importance of the "July effect."

BACKGROUND:Changes to Medicare's Inpatient Only List (IPO) and factors associated with the COVID pandemic have led to more total joint arthroplasty (TJA) patients to be designated as outpatient (OP). This potentially complicates postoperative care for patients with lower functional status and poor social support. These factors make the decision between OP versus inpatient (IP) designation particularly challenging for healthcare teams. The Risk Assessment and Prediction Tool (RAPT) was designed to indicate patient risk for needing posthospital discharge to facility and considers social and functional factors. The purpose of this study is to 1) evaluate the correlation of RAPT as a clinical tool to aid decision-making regarding OP versus IP for Total Hip and Knee Arthroplasty (THA and TKA), 2) assess the impact of recent changes to the IPO and the COVID pandemic on OP TJA readmission rates, and 3) determine whether 90-day readmissions are correlated with RAPT scores after OP TJA. METHODS:We identified all elective TKA and THA patients from 2015 through 2021 in our electronic health record at our large, urban, academic health system. Fracture patients were excluded. For those patients with available RAPT scores, we determined OP and IP designations, with IP defined as those with length-of-stay 2 midnights or more. We performed subanalysis of OP between same-day and next-day discharge. RAPT scores and readmission rates were compared at time points related to changes in the IPO: before TKA removal in 2018 (period A), from 2018 until THA removal in 2020 (Period B), and after January 1, 2020, inclusive of impact from the COVID pandemic (Period C). RESULTS:Reviewed were 11,819 elective TKAs and 10,212 elective THAs. RAPT scores were available for 6,759 TKA patients and 5,589 THA patients. For both TKA and THA, RAPT scores between IP, same-day, and next-day discharged OP were significantly different across all time periods (P < .001). The percentage of OP designation increased across all time periods for TKA and THA. Over these same time periods, mean RAPT scores decreased significantly for both OP TKA and OP THA (P < .01). Concurrent with these changes were significant increases in OP THA 90-day readmission rates across Periods A and B (P = .010) as well as A and C (P = .006). Readmitted OP TKA had significantly lower RAPT scores than OP TKA without readmission during Period B (P < .001). Readmitted OP THA had significantly lower RAPT scores than those without readmission for all periods (P < .05). To facilitate clinical utility, median RAPT scores were also analyzed, and showed that RAPT scores for OP THA patients with readmission were 1 to 2 points lower for all time periods. CONCLUSION/CONCLUSIONS:RAPT scores correlate with IP versus OP status for both TKA and THA and vary significantly with same-day versus next-day discharge. OP TJA RAPT scores may also help predict readmission, and counsel some patients away from OP surgery. Average RAPT scores of 10, 9, and 8 appeared to be separators for same day, next day, and inpatient stay. Changes to the IPO and COVID pandemic correlate with decrease in RAPT scores for both TKA and THA patients within all designations. In addition, a shift toward lower RAPT for OP TJA correlates with increased 90-day readmission rates for OP TJA. Taken together, these results suggest that patients with poorer function and worse social support systems are increasingly being driven toward OP surgery by these changes, which may play a role in increasing readmission rates. Social support and functional factors should be considered for OP elective TKA and THA. Further, any OP TJA value-based payment system must account for these variables.

BACKGROUND:Regulatory change has created a growing demand to decrease the hospital costs associated with primary total joint arthroplasty (TJA). Concurrently, the removal of lower extremity TJA from the in-patient only list has affected hospital reimbursement. The purpose of this study is to investigate trends in hospital revenue versus costs in primary TJA. METHODS:We retrospectively reviewed all patients who underwent primary TJA from June 2011 to May 2021 at our institution. Patient demographics, revenue, total cost, direct cost, and contribution margin were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analysis was used to determine overall trend significance and develop projection models. RESULTS:Total knee arthroplasty (TKA) insured by government-managed/Medicaid (GMM) plans showed a significant upward trend (p=0.013) in total costs. Direct costs of TKA across all insurance providers (p=0.001 and p<0.001) and total hip arthroplasty (THA) for Medicare (p=0.009) and GMM (p=0.001) plans demonstrated significant upward trends. Despite this, 2011 to 2021 modeling found no significant change in contribution margin for TKA and THA covered under all insurance plans. However, models based on 2018 to 2021 financial data demonstrate a significant downward trend in contribution margin across Medicare (p<0.001) and GMM (p<0.001) insurers for both TKA and THA. CONCLUSION/CONCLUSIONS:Physician-led innovation in cost-saving strategies has maintained contribution margin over the past decade. However, the increase in direct costs seen over the past few years could lead to negative contribution margins over time if further efficiency and cost-saving measures are not developed.

BACKGROUND:Surgical site infection (SSI) after total hip arthroplasty (THA) is associated with increased morbidity, mortality, and healthcare expenditures. Our institution intensified hygiene standards during the COVID-19 pandemic; hospital staff exercised greater hand hygiene, glove use, and mask compliance. We examined the effect of these factors on SSI rates for primary THA (pTHA) and revision THA (rTHA). METHODS:A retrospective review was performed identifying THA from January 2019 to June 2021 at a single institution. Baseline characteristics and outcomes were compared before (January 2019 to February 2020) and during (May 2020 to June 2021) the COVID-19 pandemic and during the first (May 2020 to November 2020) and second (December 2020 to June 2021) periods of the pandemic. Cohorts were compared using the Chi-squared test and independent samples t-test. RESULTS:A total of 2,682 pTHA (prepandemic: 1,549 [57.8%]; pandemic: 1,133 [42.2%]) and 402 rTHA (prepandemic: 216 [53.7%]; Pandemic: 186 [46.2%]) were included. For primary and revision cases, superficial and deep SSI rates were similar before and during COVID-19. During COVID-19, the incidence of all (-0.43%, P = .029) and deep (-0.36%, P = .049) SSIs decreased between the first and second periods for rTHA. pTHA patients had longer operative times (P < .001) and shorter length of stay (P = .006) during COVID-19. Revision cases had longer operative times (P = .004) and length of stay (P = .046). Both pTHA and rTHA were discharged to skilled nursing facilities less frequently during COVID-19. CONCLUSION/CONCLUSIONS:During COVID-19, operative times were longer in both pTHA and rTHA and patients were less likely to be discharged to a skilled nursing facility. Although intensified hygienic standards may lower SSI rates, infection rates did not significantly differ after our hospital implemented personal protective guidelines and a mask mandate.