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Hospital Revenue, Cost, and Contribution Margin in Inpatient vs. Outpatient Primary Total Joint Arthroplasty

Christensen, Thomas H; Bieganowski, Thomas; Malarchuk, Alex W; Davidovitch, Roy I; Bosco, Joseph A; Schwarzkopf, Ran; Macaulay, William; Slover, James; Lajam, Claudette M
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.
PMID: 35987495
ISSN: 1532-8406
CID: 5300472

Comparative Analysis of Outcomes in Medicare-Eligible Patients with a Hospital Stay Less than Two-Midnights versus Longer Length of Stay following Total Knee Arthroplasty: Implications for Inpatient-Outpatient Designation

Singh, Vivek; Lygrisse, Katherine A; Macaulay, William; Slover, James D; Schwarzkopf, Ran; Long, William J
The Centers for Medicaid and Medicare Services (CMS) removed primary total knee arthroplasty (TKA) from the inpatient-only list in January 2018. This study aims to compare outcomes in Medicare-aged patients who underwent primary TKA and had an in-hospital stay spanning less than two-midnights to those with a length of stay greater than or equal to two-midnights. We retrospectively reviewed 4,138 patients ages ≥65 who underwent primary TKA from 2016 to 2020. Two cohorts were established based on length of stay (LOS), those with an LOS <2 midnights were labeled outpatient and those with an LOS ≥2 midnights were labeled inpatient as per CMS designation. Demographic, clinical data, knee injury and osteoarthritis outcome score for joint replacement (KOOS, JR), and veterans RAND 12 physical and mental components (VR-12 PCS & MCS) were collected. Demographic differences were assessed with Chi-square and independent sample t-tests. Clinical data and KOOS, JR and VR-12 PCS and MCS scores were compared by using multilinear regression analysis, controlling for demographic differences. There were 841 (20%) patients with a LOS < 2 midnights and 3,297 (80%) patients with a LOS ≥ 2 midnights. Patients with a LOS < 2 midnights were significantly younger (71.70 vs. 73.06; p < 0.001), more likely male (42.1 vs. 25.7%; p < 0.001), Caucasian (68.8 vs. 57.7%; p <0.001), have lower BMI (30.80 vs. 31.92; p < 0.001), Charlson Comorbidity Index (CCI; 4.62 vs. 4.96; p < 0.001), and American Society of Anesthesiologists (ASA) class II or higher (p < 0.001). These patients were more likely to be discharged home compared to patients with LOS ≥ 2 midnights (95.8 vs. 73.1%; p < 0.001). Patients who stayed ≥ 2 midnights reported lower patient-reported outcome scores at all time-periods (preoperatively, 3 months and 1 year), but these differences did not exceed the minimum clinically important difference. Mean improvement preoperatively to 1 year postoperatively in KOOS, JR (22.53 vs. 25.89; p < 0.001), and VR-12 PCS (12.16 vs. 11.49; p = 0.002) was statistically higher for patients who stayed < 2 midnights, though these differences were not clinically significant. All-cause ED visits (p = 0.167), 90-day all-cause readmissions (p = 0.069) and revision (p = 0.277) did not statistically differ between the two cohorts. TKA patients classified as outpatient had similar quality metrics and saw similar clinical improvement following TKA with respect to most patient reported outcome measures, although they were demographically different. Outpatient classification is more likely to be assigned to younger males with higher functional scores, lower BMI, CCI, and ASA class compared with inpatients. This Retrospective Cohort Study shows level III evidence.
PMID: 33545728
ISSN: 1938-2480
CID: 4776792

Patient Satisfaction and Risk of Falls with the Use of Intermittent Pneumatic Compression Devices Following Total Joint Arthroplasty

Yeroushalmi, David; Padilla, Jorge A; Slover, James; Schwarzkopf, Ran; Macaulay, William
INTRODUCTION/BACKGROUND:Patients who undergo total joint arthroplasty (TJA) are at a high risk for the development of thromboembolic complications. The rate at which venous thromboembolism occurs following TJA has been reported to be between 0.5% to 1.0%. As a result, the utilization of prophylactic therapies is considered the standard of care in this patient population. The primary purpose of the current study was to 1. evaluate patient satisfaction with the home use of intermittent pneumatic compression (IPC) devices following TJA and 2. evaluate the risk of self-reported falls secondary to the use of these devices following TJA. METHODS:This is a single institution, prospective study on patients who underwent TJA at an urban, academic orthopedic specialty hospital. Utilizing an electronic patient rehabilitation application (EPRA) that wirelessly pushes digital surveys at predefined time intervals, patients were surveyed regarding their use and satisfaction with their home IPC devices. They were also asked if they experienced any falls or near-falls. Surveys were administered on postoperative day 14, and patients were given 10 days to submit their responses. Using our institutions data warehouse, patient demographics including age, sex, surgery, laterality, insurance type, and length of stay were collected. RESULTS:Survey responses were collected from 424 patients who underwent TJA between August 2018 and January 2019. Of the respondents, 248 were female and 176 were male. Approximately 79% of patients in the cohort were satisfied with their use of their compression devices compared to 21% of patients who were unsatisfied. During this time, 19.3% (82 patients) also reported at least one tripping episode at home while using the device, while 80.7% (342 patients) never had a tripping incident at home. Finally, 1.4% (six patients) had at least one fall at home, while 98.6% (418 patients) did not have any falls at home. CONCLUSION/CONCLUSIONS:These results suggest that our patients were significantly dissatisfied with their home intermittent compression devices. There are a significant number of trips or falls following TJA and further study is needed examining the potential causality of these devices and their cords in these falls.
PMID: 36030443
ISSN: 2328-5273
CID: 5331902

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty

Singh, Vivek; Tang, Alex; Bieganowski, Thomas; Anil, Utkarsh; Macaulay, William; Schwarzkopf, Ran; Davidovitch, Roy I
BACKGROUND:Patients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines. AIM/OBJECTIVE:To evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA. METHODS:We retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients' preoperative status using hierarchical Poisson and linear regressions, respectively. RESULTS:= 0.160) which correlates with a VAS pain score of 3.15. CONCLUSION/CONCLUSIONS:All patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.
PMID: 36159616
ISSN: 2218-5836
CID: 5333992

The Effect of Femoral Head Size on Groin Pain in Total Hip Arthroplasty

Moore, Michael R; Lygrisse, Katherine A; Singh, Vivek; Arraut, Jerry; Chen, Eric A; Schwarzkopf, Ran; Macaulay, William
INTRODUCTION/BACKGROUND:Although increased femoral head size reduces the risk of instability in total hip arthroplasty (THA), it may lead to iliopsoas irritation and increased anterior groin pain. The purpose of this study was to compare outcomes between non-modular dual mobility (NDM) implants, small (≤32mm), and large (≥36mm) fixed bearing (FB) constructs. METHODS:A retrospective review of all primary THAs from 2011-2021 was conducted at a single, urban academic institution. Patients were separated into three cohorts: NDM, ≤32mm, and ≥36mm FB implants. Demographics and outcomes such as length of stay (LOS), dislocation, and anterior groin pain were assessed. Patients were deemed as having groin pain if they received an iliopsoas injection or had extended physical therapy ordered beyond 3 months postoperatively. RESULTS:There were 178 NDM implants, 936 ≤32mm FB, and 2,454 ≥36mm FB implants included. LOS significantly differed between the groups (48.4±43.3 vs. 63.2±40.6 vs. 57.2±38.1 hours; p=0.001). Although not statistically significant, the ≥36mm FB cohort had the highest rate of dislocations (0.6% vs. 0.7% vs. 0.9%; p=0.84). While no patients with a NDM implant received an iliopsoas injection, 9 patients (0.9%) with a ≤32mm FB implant and 9 patients (0.4%) with a ≥36mm implant received an injection (p=0.06). However, 18 (10.1%) patients with a NDM implant, 304 (32.5%) patients with a ≤32mm FB implant, and 355 (14.5%) patients with a ≥36mm FB implant received extended physical therapy 3 months after surgery (p<0.001). CONCLUSION/CONCLUSIONS:NDM implants, as well as FB implants with both small and large head sizes are effective at preventing dislocation. NDM implants did not result in an increase in anterior groin pain compared to ≤32mm, and ≥36mm FB constructs.
PMID: 35283236
ISSN: 1532-8406
CID: 5183742

Discontinued Use of Outpatient Portable Intermittent Pneumatic Compression Devices May Be Safe for Venous Thromboembolism Prophylaxis in Primary Total Knee Arthroplasty Using Low-Dose Aspirin

Tang, Alex; Zak, Stephen; Lygrisse, Katherine; Slover, James; Meftah, Morteza; Lajam, Claudette; Schwarzkopf, Ran; Macaulay, William
Venous thromboembolism (VTE) is a rare, but serious complication following total knee arthroplasty (TKA). Current VTE guidelines recommend pharmacologic agents with or without intermittent pneumatic compression devices (IPCDs). At our institution, both 81-mg aspirin (ASA) twice a day (BID) and portable IPCDs were previously prescribed to TKA patients at standard risk for VTE, but the IPCDs were discontinued and patients were treated with ASA alone going forward. The aim of this study is to determine if discontinued use of outpatient IPCDs is safe and does not increase the rate of VTE or any other related complications in patients following TKA. A retrospective review of 2,219 consecutive TKA cases was conducted, identifying patients with VTE, bleeding complications, infection, and mortality within 90 days postoperatively. Patients were divided into two cohorts. Patients in cohort one received outpatient IPCDs for a period of 14 days (control), while those in cohort two did not (ASA alone). All study patients received inpatient IPCDs and were maintained on 81-mg ASA BID for 28 days. A posthoc power analysis was performed using a noninferiority margin of 0.25 (α = 0.05; power = 80%), which showed that our sample size was fully powered for noninferiority for our reported deep vein thrombosis (DVT) rates, but not for pulmonary embolism (PE) rates. A total of 867 controls and 1,352 patients treated with ASA alone were identified. Only two control patients were diagnosed with a PE (0.23%), while one patient in the ASA alone group had DVT (0.07%). There was no statistical difference between these rates (p = 0.33). Furthermore, no differences were found in bleeding complications (p = 0.12), infection (p = 0.97), or 90-day mortality rates (p = 0.42) between both groups. The discontinued use of outpatient portable IPCDs is noninferior to outpatient IPCD use for DVT prophylaxis. Our findings suggest that this protocol change may be safe and does not increase the rate of VTE in standard risk patients undergoing TKA while using 81-mg ASA BID.
PMID: 33241544
ISSN: 1938-2480
CID: 4680922

Evaluation of Emergency Department Visits Following Total Joint Arthroplasty: Same-Day Discharge versus Non-Same-Day Discharge

Singh, Vivek; Kurapatti, Mark; Anil, Utkarsh; Macaulay, William; Schwarzkopf, Ran; Davidovitch, Roy I
INTRODUCTION/BACKGROUND:Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty (THA and TKA) cases to determine the rate and reasons associated with 90-day ED presentations. METHODS:We retrospectively reviewed all patients who underwent primary THA and TKA between 2011-2021. The patients were separated into two cohorts: 1.)SDD;2.)required a longer length-of-stay(LOS). The primary outcome was an ED visit within 90-days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the two groups while accounting for significant demographic variables. RESULTS:Of the 24,933 patients included, 1,725(7%) were SDD and 23,208(93%) required a longer LOS. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6%vs.4.0%,p=0.004). However, when stratified based on the reason for ED visit, no single cause was significant between the two cohorts. The most commonly reported reasons were pain (32.1%vs.26.7%,p=0.064) and other non-orthopedic related medical issues (25.0%vs.29.5%,p=0.206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0%vs.23.4%,p=0.131). CONCLUSION/CONCLUSIONS:Patients that underwent SDD were less likely to present to the ED within 90-days following their surgery compared to non-SDD. Approximately three-fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system.
PMID: 35181447
ISSN: 1532-8406
CID: 5163712

Comparison of Operating Room Air Quality in Primary vs. Revision Total Knee Arthroplasty

Sicat, Chelsea Sue; Schwarzkopf, Ran; Slover, James D; Macaulay, William; Rozell, Joshua C
INTRODUCTION/BACKGROUND:Airborne biologic particles (ABPs) can be measured intraoperatively to evaluate operating room (OR) sterility. Particulate matter (PM) up to 2.5 microns can contain microbial species which may increase infection risk. Our study examines differences in air quality and ABP count in primary (pTKA) and revision total knee arthroplasty (rTKA). METHODS:We analyzed primary and revision TKAs in a single operating room at an academic institution from January 2020 to December 2020. Procedures from March 15, 2020-May 4, 2020 were excluded to avoid COVID-related confounding. Temperature, humidity, and ABP count per minute were recorded with a particle counter intraoperatively and cross-referenced with surgical data from the electronic health records (EHR) using procedure start and end times. Descriptive statistics were used to evaluate differences in variables. P-values were calculated using t-test and chi-square. RESULTS:A total of 107 TKA cases were included: 79(73.8%) pTKAs and 28(26.2%) rTKAs. Time spent in room was significantly higher for rTKAs (primary: 176+46.7 minutes vs. revision: 220+47.1,p<0.0001). Compared to pTKAs, rTKAs had significant percent increases in ABP rates for particles measuring 0.3um(+70.4%,p<0.001), 0.5um(+97.2%,p<0.0001), 1.0um(+53.2%,p=0.001), 2.5um(+30.3%,p=0.017), and for PM 2.5(+108.3%,p<0.001) and PM5.0(+105.6%,p<0.001). CONCLUSION/CONCLUSIONS:RTKAs had significantly longer time spent in room and significant percent increases in ABP rates for particles measuring 0.3um, 0.5um, and 1.0um compared to pTKAs. Measurements of PM2.5 and PM5.0 (which can contain large numbers of microbes) were also significantly greater in rTKAs. Further research is needed to determine whether the size and quantity of ABPs translates to higher infection rates following rTKA.
PMID: 35202754
ISSN: 1532-8406
CID: 5172342

Dual-mobility versus Fixed-bearing in Primary Total Hip Arthroplasty: Outcome Comparison

Singh, Vivek; Loloi, Jeremy; Macaulay, William; Hepinstall, Matthew S; Schwarzkopf, Ran; Aggarwal, Vinay K
Purpose/UNASSIGNED:Use of dual mobility (DM) articulations can reduce the risk of instability in both primary and revision total hip arthroplasty (THA). Knowledge regarding the impact of this design on patient-reported outcome measures (PROMs) is limited. This study aims to compare clinical outcomes between DM and fixed bearing (FB) prostheses following primary THA. Materials and Methods/UNASSIGNED:All patients who underwent primary THA between 2011-2021 were reviewed retrospectively. Patients were separated into three cohorts: FB vs monoblock-D vs modular-DM. An evaluation of PROMs including HOOS, JR, and FJS-12, as well as discharge-disposition, 90-day readmissions, and revisions rates was performed. Propensity-score matching was performed to limit significant demographic differences, while ANOVA and chi-squared test were used for comparison of outcomes. Results/UNASSIGNED:=0.608) between the groups. Conclusion/UNASSIGNED:DM bearings yield PROMs similar to those of FB implants in patients undergoing primary THA. Although DM implants are utilized more often in patients at higher-risk for instability, we suggest that similar patient satisfaction may be attained while achieving similar dislocation rates.
PMID: 35800126
ISSN: 2287-3260
CID: 5280612

Preoperative Patient Expectation of Discharge Planning is an Essential Component in Total Knee Arthroplasty

Feng, James E; Anoushiravani, Afshin A; Morton, Jessica S; Petersen, William; Singh, Vivek; Schwarzkopf, Ran; Macaulay, William
PURPOSE/OBJECTIVE:A better understanding of total knee arthroplasty (TKA) candidate expectations within the perioperative setting will enable clinicians to promote patient-centered practices, optimize recovery times, and enhance quality metrics. In the current study, TKA candidates were surveyed pre- and postoperatively to elucidate the relationship between patient expectations and length of stay (LOS). MATERIAL AND METHODS/METHODS:This is a prospective study of patients undergoing TKA between December 2017 and August 2018. Patients were electronically administered surveys regarding their discharge plan 10 days pre-/postoperatively. All patients were categorized into three cohorts based on their LOS: 1, 2, and 3+ days. The effect of preoperative discharge education on patient postoperative satisfaction was evaluated. RESULTS:In total, 221 TKAs were included, of which 83 were discharged on postoperative day (POD) 1, 96 on POD-2, and 42 POD-3+. Female gender, increasing body mass index (BMI), and surgical time correlated with increased LOS. Preoperative discussions regarding LOS occurred in 84.62% (187/221) of patients but did correlate with differences in LOS. However, patients discharged on POD-1 were more inclined to same-day surgery preoperatively. Patients discharged on POD-3+ were found to be more uncomfortable regarding their discharge during the preoperative phase. Multivariable regressions demonstrated that preoperative discharge discussion was positively correlated with home discharge. CONCLUSION/CONCLUSIONS:Physician-driven discussion regarding patient discharge did not alter patient satisfaction or length of stay but did correlate with improved odds of home discharge. These findings underscore the importance of patient education, shared decision-making, and managing patient expectations.
PMID: 35527265
ISSN: 2234-0726
CID: 5214032