Faculty Bibliography

BACKGROUND:On December 20, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized its proposed rule: CMS-1734-P. This 2021 Final Rule significantly changed Medicare total joint arthroplasty (TJA) reimbursement. The precise impact on surgeon productivity and reimbursement is unknown. In the present study, we sought to model the potential impact of these changes for multiple unique practice configurations. METHODS:A mathematical model was applied to CMS data to determine the impact of CMS-1734-F on multiple, theoretical TJA practice configurations. Variables tested were the annual percentage of revision vs primary arthroplasty cases performed and the annual percentage of operative vs office-based productivity. The model defined baseline annual surgeon productivity as the 2018 Medical Group Management Association hip and knee arthroplasty surgeon median productivity of 10,568 work relative value units (wRVUs). RESULTS:All modeled simulations demonstrated a year-to-year increase in wRVUs independent of practice configuration. However, simulations that demonstrated less than a 3.35% increase in wRVUs from year-to-year saw a decrease in reimbursement. Those simulations with higher wRVU increases tended to have a higher percentage of revision vs primary arthroplasty cases and/or had annual productivity that was derived to a greater extent from office encounters than surgical cases. CONCLUSION/CONCLUSIONS:The impact of CMS-1734-F will vary based on 3 factors: (1) the relative contribution of a surgeon's operative TJA practice compared with their office-based practice to their annual wRVUs; (2) the relative percentage of revision TJAs vs the percentage of primary TJAs performed; and (3) the relative percentage of primary TJA compared to non-arthroplasty surgeries as a component of overall operative practice. The decreased reimbursement will be disproportionately felt by arthroplasty surgeons who perform relatively fewer revision TJA procedures and whose office-based productivity makes up a smaller overall percentage of their annual workload.

BACKGROUND:Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections. METHODS:We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups. RESULTS:We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012). CONCLUSION/CONCLUSIONS:Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.

ABSTRACT/UNASSIGNED:The shift to value-based care is changing the practice of medicine. In order to prepare our orthopaedic trainees to survive in a value-based health-care environment, we must expose them to and educate them about value-based programs. This creates both challenges and opportunities for training programs. Academic medical centers (AMCs) will need to carefully consider how to adopt value-based programs and agreements, and assess whether they need alternative facilities, partnerships, or processes in order to be successful. Process improvement principles to adapt physician behavior, the introduction of outcome metrics into the surgical decision-making process, and the development of team-based care can greatly enhance the likelihood of success. AMCs should embrace these challenges to ensure that their residents are well-prepared for the future.

BACKGROUND:The number of octogenarians requiring a total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) will rise disproportionally in the coming decade. Although outcomes are comparable with younger patients, management of these older patients involves higher medical complexity at a greater expense to the hospital system. The purpose of this study was to compare the cost of care for primary THA and TKA in our bundled care patients aged ≥80 years to those aged 65-80 years. METHODS:A retrospective review of primary TKA (n = 641) and THA (n = 1225) cases from 2013 to 2017 was performed. Patient demographic and admission cost data were collected. Patients were grouped based on surgery type (ie, elective or nonelective THA/TKA) and age group (ie, older [≥80 years old] or younger [65-80 years old]). Multivariate regression analyses were used to account for demographic differences. RESULTS:Elective primary THA in the older cohort (n = 157) cost 24.5% more than the younger cohort (n = 1025) (P < .0001). Elective primary TKA cases in the older cohort (n = 87) cost 17.0% more than the younger cohort's (n = 554) (P < .0001). For nonelective THA cases, the older cohort's (n = 29) episodes cost 39.1% more than the younger cohort (n = 14) (P < .0001). When comparing the <80 elective THA cohort (n = 1025) to the ≥90 cohort (n = 10), the cost difference swelled to 58.7% (P < .0001). CONCLUSION/CONCLUSIONS:Although primary THA and TKA in ≥80-year-old patients yield similar outcomes, this study demonstrates that the additional measures required to care for older patients and ensure successful outcomes cost significantly more. Consideration should be given to age as a factor in determining reimbursement in a bundled payment system to reduce the incentive to restrict care to elderly patients.