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OBJECTIVES: Physical and cognitive conditions of patients discharged to skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home with home health agencies (HHAs) following total joint arthroplasty (TJA) have not been evaluated. The purpose of this study is to examine the physical and cognitive function trends of Medicare beneficiaries discharged to SNFs, HHAs, and IRFs following TJA from 2013 to 2018. DESIGN: Observational study using Medicare enrollment, claims, and assessment data from 2013-2018. SETTING AND PARTICIPANTS: 1,278,939 Medicare beneficiaries discharged to SNFs, HHAs, or IRFs for post-acute care following TJA from 2013 to 2018. METHODS: Medicare data were used to examine the association between the endpoints of interest [discharge destination (SNF, HHA, or IRF) and the physical (measured using activities of daily living) and cognitive (measured using a range of setting-specific metrics) status of patients in each setting] and the year of TJA (2013-2018) by estimating multivariable models that controlled for patient- and hospital-level covariates. RESULTS: Multivariable analysis of 1,278,939 TJAs revealed that SNF discharge decreased [44.15% (2013)-21.57% (2018), P < .001], HHA increased (46.72%-72.47%, P < .001), and IRF decreased (9.13%-5.69%, P < .001). For SNF, the mean physical function scores [14.61 (2013)-14.23 (2018), P < .001] and cognitive impairment (13.25%-12.33%, P = .01) decreased, indicating less dependence. Physical function scores (3.09-3.94, P < .001) and cognitive impairment (13.95%-16.52%, P < .001) increased for HHA patients, indicating greater dependence. For IRF, motor functional independence measure decreased (38.81-37.78, P < .001) and cognitive dependence increased (39.08%-46.36%, P < .001), indicating greater dependence. CONCLUSIONS AND IMPLICATIONS: From 2013 to 2018, patients were increasingly discharged to HHA. Although SNF patients were less dependent over time, HHA and IRF patients were physically and cognitively more dependent. Each setting is likely to benefit from policy and fiscal supports that help them manage changes in the volume and clinical intensity of patients requiring their services.

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Background: 25-hydroxy Vitamin D (25[OH]D) level has been shown to have antimicrobial and wound healing effects in animal models. Low preoperative 25(OH)D has been shown to correlate with surgical site infection (SSI) in thoracolumbar spine surgery. Methods: This study involved 545 patients undergoing thoracolumbar spine surgery from 2012 to 2019 at an academic medical center. We evaluated the serum 25(OH)D level (i.e., adequate level = level 30-60 ng/dL), along with SSI, body mass index, and smoking status. Statistical analysis was done using bivariate analysis with Fisher's exact, Wilcoxon rank-sum test and multivarible logisitic regression analyses. Results: We included 545 patients in the study, and there were no statistical differences in the average preoperative 25(OH)D between SSI and non-SSI groups. The average 25(OH)D in the non-SSI group was 31.6 ng/dL ± 13.6, and the SSI group was 35.7 ng/dL ± 20.2 (P = 0.63). Conclusion: SSI rates following thoracolumbar spine surgery were not affected by preoperative 25(OH)D levels.

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Objective To explore how socioeconomic status and patient characteristics may be associated with initial self-reports of pain and determine if there was an increased association with undergoing spine surgery. Methods Patients at an academic center between 2015 and 2021 who completed the Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) questionnaire were included. Multivariable linear regression models were used to determine the association between insurance type and patient factors with initial reports of pain. Multivariable logistic regression models were used to determine the association between PI and the likelihood of surgery in two time periods, three and 12 months. Results The study included 9,587 patients. The mean PROMIS-PI scores were 61.93 (SD 7.82) and 63.74 (SD 6.93) in the cervical and lumbar cohorts, respectively. Medicaid and Workers' Compensation insurance patients reported higher pain scores compared to those with private insurance: Medicaid (cervical: 2.77, CI (1.76-3.79), p<0.001; lumbar (2.05, CI (1.52-2.59), p<0.001); Workers' Compensation (cervical: 2.12, CI (0.96-3.27), p<0.001; lumbar: 1.51, CI (0.79-2.23), p<0.001). Black patients reported higher pain compared to White patients (cervical: 1.50, CI (0.44-2.55), p=0.01; lumbar: 1.51, CI (0.94-2.08), p<0.001). Higher PROMIS-PI scores were associated with a higher likelihood of surgery. There was no increased association of likelihood of surgery in Black, Medicaid, or Workers' Compensation patients when controlling for pain severity. Conclusion Black patients and patients with Medicaid and Workers' compensation insurance were likely to report higher pain scores. Higher initial pain scores were associated with an increased likelihood of surgery. However, despite increased pain scores, Black patients and those with Medicaid and Workers' Compensation insurance did not have a higher likelihood of undergoing surgery.

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BACKGROUND: The Medicare Merit-based Incentive Payment System (MIPS) ties reimbursement incentives to clinician performance to improve healthcare quality. It is unclear whether the MIPS quality score can accurately distinguish between high-performing and low-performing clinicians. QUESTIONS/PURPOSES: (1) What were the rates of unplanned hospital visits (emergency department visits, observation stays, or unplanned admissions) within 7, 30, and 90 days of outpatient orthopaedic surgery among Medicare beneficiaries? (2) Was there any association of MIPS quality scores with the risk of an unplanned hospital visit (emergency department visits, observation stays, or unplanned admissions)? METHODS: Between January 2018 and December 2019, a total of 605,946 outpatient orthopaedic surgeries were performed in New York State according to the New York Statewide Planning and Research Cooperative System database. Of those, 56,772 patients were identified as Medicare beneficiaries and were therefore potentially eligible. A further 34% (19,037) were excluded because of missing surgeon identifier, age younger than 65 years, residency outside New York State, emergency department visit on the same day as outpatient surgery, observation stay on the same claim as outpatient surgery, and concomitant high-risk or eye procedures, leaving 37,735 patients for analysis. The database does not include a list of all state residents and thus does not allow for censoring of patients who move out of state. We chose this dataset because it includes nearly all hospitals and ambulatory surgery centers in a large geographic area (New York State) and hence is not limited by sampling bias. We included 37,735 outpatient orthopaedic surgical encounters among Medicare beneficiaries in New York State from 2018 to 2019. For the 37,735 outpatient orthopaedic surgical procedures included in our study, the mean ± standard deviation age of patients was 73 ± 7 years, 84% (31,550) were White, and 59% (22,071) were women. Our key independent variable was the MIPS quality score percentile (0 to 19th, 20th to 39th, 40th to 59th, or 60th to 100th) for orthopaedic surgeons. Clinicians in the MIPS program may receive a bonus or penalty based on the overall MIPS score, which ranges from 0 to 100 and is a weighted score based on four subscores: quality, promoting interoperability, improvement activities, and cost. The MIPS quality score, which attempts to reward clinicians providing superior quality of care, accounted for 50% and 45% of the overall MIPS score in 2018 and 2019, respectively. Our main outcome measures were 7-day, 30-day, and 90-day unplanned hospital visits after outpatient orthopaedic surgery. To determine the association between MIPS quality scores and unplanned hospital visits, we estimated multivariable hierarchical logistic regression models controlling for MIPS quality scores; patient-level (age, race and ethnicity, gender, and comorbidities), facility-level (such as bed size and teaching status), surgery and surgeon-level (such as surgical procedure and surgeon volume) covariates; and facility-level random effects. We then used these models to estimate the adjusted rates of unplanned hospital visits across MIPS quality score percentiles after adjusting for covariates in the multivariable models. RESULTS: In total, 2% (606 of 37,735), 2% (783 of 37,735), and 3% (1013 of 37,735) of encounters had an unplanned hospital visit within 7, 30, or 90 days of outpatient orthopaedic surgery, respectively. Most hospital visits within 7 days (95% [576 of 606]), 30 days (94% [733 of 783]), or 90 days (91% [924 of 1013]) were because of emergency department visits. We found very small differences in unplanned hospital visits by MIPS quality scores, with the 20th to 39th percentile of MIPS quality scores having 0.71% points (95% CI -1.19% to -0.22%; p = 0.004), 0.68% points (95% CI -1.26% to -0.11%; p = 0.02), and 0.75% points (95% CI -1.42% to -0.08%; p = 0.03) lower than the 0 to 19th percentile at 7, 30, and 90 days, respectively. There was no difference in adjusted rates of unplanned hospital visits between patients undergoing surgery with a surgeon in the 0 to 19th, 40th to 59th, or 60th to 100th percentiles at 7, 30, or 90 days. CONCLUSION: We found that the rates of unplanned hospital visits after outpatient orthopaedic surgery among Medicare beneficiaries were low and primarily driven by emergency department visits. We additionally found only a small association between MIPS quality scores for individual physicians and the risk of an unplanned hospital visit after outpatient orthopaedic surgery. These findings suggest that policies aimed at reducing postoperative emergency department visits may be the best target to reduce overall postoperative unplanned hospital visits and that the MIPS program should be eliminated or modified to more strongly link reimbursement to risk-adjusted patient outcomes, thereby better aligning incentives among patients, surgeons, and the Centers for Medicare ad Medicaid Services. Future work could seek to evaluate the association between MIPS scores and other surgical outcomes and evaluate whether annual changes in MIPS score weighting are independently associated with clinician performance in the MIPS and regarding clinical outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

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BACKGROUND: Cementless total knee arthroplasty (TKA) has increased in popularity to potentially improve survivorship. Radiostereometric studies demonstrate increased component migration during the first 3 to 6 months in cementless constructs, generating concern for increased postoperative pain during early osseointegration. The purpose of this study was to evaluate short-term (≤ 6 months) pain and function in cemented versus cementless TKA. We hypothesized that cementless TKA patients report increased pain during the short-term (≤ 6 months) postoperative period. METHODS: The MEDLINE, EMBASE, CINAHL, and Cochrane Libraries were searched for studies evaluating short-term (≤ 6 months) outcomes of cemented versus cementless primary TKA. Studies involving hybrid fixation were excluded. A meta-analysis was performed using standardized mean difference for primary outcomes (early postoperative pain) and weighted mean difference (WMD) for secondary outcomes (early postoperative function). RESULTS: There were eleven studies included. There was no significant difference in acute postoperative pain between cemented and cementless TKA within 6 months of index TKA (standardized mean difference 0.08 in favor of cemented TKA; P = .10). Early postoperative forgotten joint scores (WMD 0.81; P = .81) and knee injury and osteoarthritis outcome scores for joint replacement (WMD 0.80 in favor of cemented TKA; P = .14) were also similar between groups. CONCLUSIONS: There is no difference in short-term (≤ 6 months) pain or early function between patients receiving cemented and cementless TKA. This suggests that surgeons may utilize cementless TKA without fear of increased pain due to micromotion within 6 months of index arthroplasty. However, additional studies with uniform assessment methods are needed to further inform differences in short-term pain and early functional outcomes between cemented and cementless TKA.

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BACKGROUND: National campaigns in the United States, such as Choosing Wisely, emphasize that decreasing low-value office visits maximizes health care value. Although patient-reported outcomes (PROs) are frequently used to quantify postoperative outcomes, they have not been assessed as a tool to help guide clinicians consider alternatives or discontinue in-person follow-up visits. The purpose of this study is to assess the frequency and cost of in-person follow-up visits after patients report substantial improvement defined as 2 consecutive improvements above preoperative Patient Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores. METHODS: Retrospective PROMIS PI data were obtained between 2015 and 2020 for common elective foot (n = 759) and ankle (n = 578) surgical procedures. Patients were divided into quartiles according to their preoperative PI score. Multivariable Cox proportional hazards models were used to investigate time to substantial improvement. Substantial improvement was defined as having 2 consecutive postoperative minimal clinically important differences (MCIDs) above preoperative PROMIS PI scores. MCID was measured using the distribution-based method. Multivariable negative binomial models were used to determine the number of visits and direct associated costs after substantial improvement. The cost to payors was estimated using reimbursement rates. RESULTS: Within 3 months, 12% to 46% of foot and 16% to 61% of ankle patients achieved substantial improvement. Results vary by preoperative pain quartile, with patients who report higher preoperative pain scores achieving earlier improvement. After achieving substantial improvement, foot and ankle patients averaged 3.60 and 4.01 follow-up visits during the remaining 9 months of the year. Visit costs averaged $266 and $322 per foot and ankle patient respectively. CONCLUSION: Postoperative follow-up visits are time-consuming and costly. Physicians might consider objective measures, such as PROMIS PI, to determine the need, timing, and alternatives for in-person follow-up visits for elective foot and ankle surgeries after patients demonstrate reliable clinical improvement. LEVEL OF EVIDENCE: Level III, retrospective cohort study at a single institution.

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INTRODUCTION: The use of antibiotic-laden bone cement (ALBC) for infection prophylaxis in the setting of primary total knee arthroplasty (TKA) remains controversial. Using data from the American Joint Replacement Registry (AJRR), (1) we examined the demographics of ALBC usage in the United States and (2) identified the effect of prophylactic commercially available ALBC on early revision and readmission for prosthetic joint infection (PJI) after primary TKA. METHODS: This is a retrospective cohort study of the AJRR from 2017 to 2020. Patients older than 65 years undergoing primary cemented TKA with or without the use of commercially available antibiotic cement were eligible for inclusion (N = 251,506 patients). Data were linked to available Medicare claims to maximize revision outcomes. Demographics including age, sex, race/ethnicity, Charlson Comorbidity Index (CCI), preoperative inflammatory arthritis, region, and body mass index (BMI) class were recorded. Cox proportional hazards regression analysis was used to evaluate the association between the two outcome measures and ALBC usage. RESULTS: Patients undergoing cemented TKA with ALBC were more likely to be Non-Hispanic Black ( P < 0.001), have a CCI of 2 or 3 ( P < 0.001), reside in the South ( P < 0.001), and had a higher mean BMI ( P < 0.001). In the regression models, ALBC usage was associated with increased risk of 90-day revision for PJI (hazards ratio 2.175 [95% confidence interval] 1.698 to 2.787) ( P < 0.001) and was not associated with 90-day all-cause readmissions. Male sex, higher CCI, and BMI >35 were all independently associated with 90-day revision for PJI. DISCUSSION: The use of commercial ALBC in patients older than 65 years for primary TKA in the AJRR was not closely associated with underlying comorbidities suggesting that hospital-level and surgeon-level factors influence its use. In addition, ALBC use did not decrease the risk of 90-day revision for PJI and was not associated with 90-day readmission rates.

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BACKGROUND: Obesity is considered a modifiable risk factor prior to total knee arthroplasty (TKA); however, little data support this hypothesis. Our purpose was to evaluate patients who have a body mass index (BMI) >40 presenting for TKA to determine the incidence of: (1) patients who achieved successful weight loss through nutritional modification or bariatric surgery and (2) patients who underwent TKA over the study period without the presence of a formal optimization program. METHODS: This was a retrospective, single-center analysis. Inclusion criteria included: Kellgren and Lawrence grade 3 or 4 knee osteoarthritis, BMI >40 at presentation, and minimum 1-year follow-up (mean 45 months) (N = 624 patients). Demographics, weight loss interventions, pursuit of TKA, maximum BMI change, and Patient-Reported Outcomes Measurement Information System scores were collected. Multivariable logistic and linear regressions evaluated associations of underlying demographic and treatment characteristics with outcomes. RESULTS: There were 11% of patients who ended up pursuing TKA over the study period. Bariatric surgery was 3.7 times more likely to decrease BMI by minimum 10 compared to nonsurgical intervention (95% confidence interval [CI] [1.7, 8.1]; P = .001). Bariatric surgery resulted in mean BMI change of -3.3 (range, 0 to 22) compared to nonsurgical interventions (-2.6 [range, 0 to 12]) and no intervention (0.4 [range, 0 to 15]; P < .0001). Bariatric surgery patients were 3.1 times more likely to undergo TKA (95% CI [1.3, 7.1]; P = .008), and nonsurgical interventions were 2.4 times more likely to undergo TKA (95% CI [1.3, 4.5]; P = .006) compared to no intervention. Non-White patients across all interventions were less likely to experience loss >5 BMI compared to White patients (95% CI [0.2, 0.9]; P = .018). CONCLUSIONS: Most patients were unable to reduce BMI more than 5 to 10 over a mean 4-year period without a formal weight optimization program. Utilization of bariatric surgery was most successful compared to nonsurgical interventions, although ultimate pursuit of TKA remained low in all cohorts.

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BACKGROUND: Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries. METHODS: We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering. RESULTS: Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002). CONCLUSIONS: Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.

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BACKGROUND: The annual volume of carpal tunnel release (CTR) in the United States has been estimated to be 577 000 per year. Our objectives were to evaluate the incidence and risk factors for revision CTR within 1 year of primary CTR. METHODS: We identified all adult patients undergoing primary CTR from October 2015 to September 2019 in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology (CPT) codes. We used the CPT modifier codes to determine laterality of index and revision procedures. We estimated multivariable hierarchical logistic regression models to evaluate risk factors for revision CTR within 1 year. RESULTS: Of the 80 423 primary CTR procedures, 178 (0.22%) underwent a revision CTR within 1 year of the index surgery. The mean (SD) age of the entire cohort was 58.69 (14.43) years, 61.1% were women, 73.2% were non-Hispanic white, 42.9% were covered through private insurance, and 9.5% had diabetes mellitus. Workers' compensation insurance (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.13-2.98, P = .02) and simultaneous bilateral CTR (OR = 14.91, 95% CI, 9.62-23.12, P < .001) were associated with revision CTR within 1 year of the index procedure. No models demonstrated an association between endoscopic technique or surgeon volume and revision CTR. CONCLUSIONS: The incidence of revision CTR within 1 year was lower than that previously reported. Patients covered by workers' compensation and those undergoing simultaneous bilateral CTR had higher likelihood of a revision CTR within 1 year, whereas endoscopic technique and surgeon volume were not associated with revision CTR within 1 year.

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BACKGROUND: The purpose of the study was to use Machine Learning (ML) to construct a risk calculator for patients who undergo Total Joint Arthroplasty (TJA) on the basis of New York State Statewide Planning and Research Cooperative System (SPARCS) data and externally validate the calculator on a single TJA center. METHODS: Seven ML algorithms, i.e., logistic regression, adaptive boosting, gradient boosting (Xg Boost), random forest (RF) classifier, support vector machine, and single and a five-layered neural network were trained on the derivation cohort. Models were trained on 68% of data, validated on 15%, tested on 15%, and externally validated on 2% of the data from a single arthroplasty center. RESULTS: Validation of the models showed that the RF classifier performed best in terms of 30-d mortality AUROC (Area Under the Receiver Operating Characteristic) 0.78, 30-d readmission (AUROC 0.61) and 90-d composite complications (AUROC 0.73) amongst the test set. Additionally, Xg Boost was found to be the best predicting model for 90-d readmission and 90-d composite complications (AUC 0.73). External validation demonstrated that models achieved similar AUROCs to the test set although variation occurred in top model performance for 90-d composite complications and readmissions between our test and external validation set. CONCLUSION: This was the first study to investigate the use of ML to create a predictive risk calculator from state-wide data and then externally validate it with data from a single arthroplasty center. Discrimination between best performing ML models and between the test set and the external validation set are comparable. LEVEL OF EVIDENCE: III.

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BACKGROUND CONTEXT: The extent to which use of spine surgeries for patients with cervical and lumbar disorders varies by their race/ethnicity and income is currently unknown. PURPOSE: To assess racial/ethnic and income-based differences in use of spine surgery in New York State (NYS) from 2016 to 2019. STUDY DESIGN: Retrospective observational analysis using 2016 to 2019 New York Statewide Planning and Research Cooperative System (SPARCS) data, direct standardization, and multivariable mixed-effects linear regression models. METHODS: A dataset of patients who underwent surgery for cervical and spinal disorders in NYS in the period 2016 to 2019 was used to determine county-level age- and sex-standardized annual cervical and lumbar surgery rates expressed as number of surgeries per 10,000 individuals. Further sub-analysis was performed with the key independent variables being the combination of individual-level race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic individuals) and income (low-/high-income residing in zip codes below/above state median income); and year. We estimated multivariable mixed-effects linear regression models which controlled county-level variables to determine the adjusted rates of spine surgeries for patients belonging to various race/ethnicity and income group combinations. RESULTS: The study included 29,650 and 42,498 patients in the cervical and lumbar cohorts, respectively. In 2019, the county-level mean cervical and lumbar surgery rates were 3.88 and 5.19 surgeries per 10,000 individuals, respectively. There was a five-fold rate variation across NYS. In 2019, the adjusted cervical rates were 4.59 (White low-income), 4.96 (White high-income), 7.20 (Black low-income), 3.01 (Black high-income), 4.37 (Hispanic low-income), and 1.17 (Hispanic high-income). The adjusted lumbar rates were 5.49 (White low-income), 6.31 (White high-income), 9.43 (Black low-income), 2.47 (Black high-income), 4.22 (Hispanic low-income), and 2.02 (Hispanic high-income). The rates for low-income Black or Hispanic patients were significantly higher than their high-income counterparts. Low-income Black patients had the highest rates. Over the study period, the gap/difference increased significantly between high-income Hispanic and White individuals by 2.19 (95% confidence interval [CI]: -4.27, -0.10, p=.04) for cervical surgery; and between low-income Black and White individuals by 2.82 (2.82, 95% CI: 0.59, 5.06, p=.01) for lumbar surgery. CONCLUSION: There are differences in the rates of spine surgery in New York State, among identifiable groups. Black individuals from poorer zip codes experience relatively higher spine surgery rates. Understanding the drivers of surgical rate variation is key to improving the equitable delivery of spine care. A better understanding of such rate variations could inform health policy.

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PURPOSE: (1) Identification of musculoskeletal risk factors for healthcare providers suffering low back pain (LBP) and the creation of risk profiles for those individuals and (2) analyze the impact of a workplace wellness program on healthcare providers who suffer from low back pain. METHODS: A total of 3040 employees at an academic healthcare center underwent a computer-adaptive survey of health-related quality of life (HRQOL), biometric tests, and a disability and functional movement assessment as part of the workplace wellness program (WWP). Clinical interventions with a rehabilitation specialist were offered to employees identified as at risk for low back pain. Data collected were analyzed using descriptive methods and multivariable regressions to address the study objectives. RESULTS: Of the 3040 healthcare providers enrolled in this study, 77% identified with non-specific LBP with greater weakness, numbness, reduced flexibility, and physical activity. The major predictive risk factors for LBP were Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference score, PROMIS fatigue, previous work injury, flexibility, numbness, PROMIS social function, level of education, and BMI. Healthcare providers with LBP who completed the WWP improved in most dimensions of HRQOL and disability and functional outcomes. CONCLUSIONS: A high proportion of healthcare providers suffer from LBP as a result of the nature of their work. Disability and functional outcomes measurements and PROMIS results quantitatively assess healthcare providers with LBP. Organizations can develop injury mitigation programs to target employees at high risk of LBP using the risk factors we identify. Completion of the WWP was associated with improvements in disability, HRQOL and functional measures.

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PURPOSE OF REVIEW: The purpose of this review is to synthesize the recently published scientific evidence on disparities in epidemiology and management of fragility hip fractures. RECENT FINDINGS: There have been a number of investigations focusing on the presence of disparities in the epidemiology and management of fragility hip fractures. Race-, sex-, geographic-, socioeconomic-, and comorbidity-based disparities have been the primary focus of these investigations. Comparatively fewer studies have focused on why these disparities may exist and interventions to reduce disparities. There are widespread and profound disparities in the epidemiology and management of fragility hip fractures. More studies are needed to understand why these disparities exist and how they can be addressed.

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Importance: Little is known about the association of total knee replacement (TKR) removal from the Medicare inpatient-only (IPO) list in 2018 with outcomes in Medicare patients. Objective: To evaluate (1) patient factors associated with outpatient TKR use and (2) whether the IPO policy was associated with changes in postoperative outcomes for patients undergoing TKR. Design, Setting, and Participants: This cohort study included data from administrative claims from the New York Statewide Planning and Research Cooperative System. Included patients were Medicare fee-for-service beneficiaries undergoing TKRs or total hip replacements (THRs) in New York State from 2016 to 2019. Multivariable generalized linear mixed models were used to identify patient factors associated with outpatient TKR use, and with a difference-in-differences strategy to examine association of the IPO policy with post-TKR outcomes relative to post-THR outcomes in Medicare patients. Data analysis was performed from 2021 to 2022. Exposures: IPO policy implementation in 2018. Main Outcomes and Measures: Use of outpatient or inpatient TKR; secondary outcomes included 30-day and 90-day readmissions, 30-day and 90-day postoperative emergency department visits, non-home discharge, and total cost of the surgical encounter. Results: A total of 37 588 TKR procedures were performed on 18 819 patients from 2016 to 2019, with 1684 outpatient TKR procedures from 2018 to 2019 (mean [SD] age, 73.8 [5.9] years; 12 240 female [65.0%]; 823 Hispanic [4.4%], 982 non-Hispanic Black [5.2%], 15 714 non-Hispanic White [83.5%]). Older (eg, age 75 years vs 65 years: adjusted difference, -1.65%; 95% CI, -2.31% to -0.99%), Black (-1.44%; 95% CI, -2.81% to -0.07%), and female patients (-0.91%; 95% CI, -1.52% to -0.29%), as well as patients treated in safety-net hospitals (disproportionate share hospital payments quartile 4: -18.09%; 95% CI, -31.81% to -4.36%), were less likely to undergo outpatient TKR. After IPO policy implementation in the TKR cohort, there were lower adjusted 30-day readmissions (adjusted difference [AD], -2.11%; 95% CI, -2.73% to -1.48%; P < .001), 90-day readmissions ( -3.23%; 95% CI, -4.04% to -2.42%; P < .001), 30-day ED visits ( -2.45%; 95% CI, -3.17% to -1.72%; P < .001), 90-day ED visits (-4.01%; 95% CI, -4.91% to -3.11%; P < .001) and higher cost per encounter ($2988; 95% CI, $415 to $5561; P = .03). However, these changes did not differ from changes in the THR cohort except for increased TKR cost of $770 per encounter ($770; 95% CI, $83 to $1457; P = .03) relative to THR. Conclusions and Relevance: In this cohort study of patients undergoing TKR and THR, we found that older, Black, and female patients and patients treated in safety-net hospitals may have had lesser access to outpatient TKRs highlighting concerns of disparities. IPO policy was not associated with changes in overall health care use or outcomes after TKR, except for an increase of $770 per TKR encounter.

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BACKGROUND: It has been shown that patient demographics such as age, payer factors such as insurance type, clinical characteristics such as preoperative opioid use, and disease grade but not surgical procedure are associated with revision surgery to treat cubital tunnel syndrome. However, prior studies evaluating factors associated with revision surgery after primary cubital tunnel release have been relatively small and have involved patients from a single institution or included only a single payer. QUESTIONS/PURPOSES: (1) What percentage of patients who underwent cubital tunnel release underwent revision within 3 years? (2) What factors are associated with revision cubital tunnel release within 3 years of primary cubital tunnel release? METHODS: We identified all adult patients who underwent primary cubital tunnel release from January 1, 2011, to December 31, 2017, in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology codes. We chose this database because it includes all payers and nearly all facilities in a large geographic area where cubital tunnel release may be performed. We used Current Procedural Terminology modifier codes to determine the laterality of primary and revision procedures. The mean age of the cohort overall was 53 ± 14 years, 43% (8490 of 19,683) were women, and 73% (14,308 of 19,683) were non-Hispanic White. The Statewide Planning and Research Cooperative System database organization does not include a listing of all state residents and thus does not allow for censoring of patients who move out of state. All patients were followed for 3 years. We developed a multivariable hierarchical logistic regression model to model factors independently associated with revision cubital tunnel release within 3 years. Key explanatory variables included age, gender, race or ethnicity, insurance, patient residential location, medical comorbidities, concomitant procedures, whether the procedure was unilateral or bilateral, and year. The model also controlled for facility-level random effects to account for the clustering of observations among these entities. RESULTS: The risk of revision cubital tunnel release within 3 years of the primary procedure was 0.7% (141 of 19,683). The median time to revision cubital tunnel release was 448 days (interquartile range 210 to 861 days). After controlling for patient-level covariates and facility random effects, and compared with their respective counterparts, the odds of revision surgery were higher for patients with workers compensation insurance (odds ratio 2.14 [95% confidence interval 1.38 to 3.32]; p < 0.001), a simultaneous bilateral index procedure (OR 12.26 [95% CI 5.93 to 25.32]; p < 0.001), and those who underwent submuscular transposition of the ulnar nerve (OR 2.82 [95% CI 1.35 to 5.89]; p = 0.006). The odds of revision surgery were lower with increasing age (OR 0.79 per 10 years [95% CI 0.69 to 0.91]; p < 0.001) and a concomitant carpal tunnel release (OR 0.66 [95% CI 0.44 to 0.98]; p = 0.04). CONCLUSION: The risk of revision cubital tunnel release was low. Surgeons should be cautious when performing simultaneous bilateral cubital tunnel release and when performing submuscular transposition in the setting of primary cubital tunnel release. Patients with workers compensation insurance should be informed they are at increased odds for undergoing subsequent revision cubital tunnel release within 3 years. Future work may seek to better understand whether these same effects are seen in other populations. Future work might also evaluate how these and other factors such as disease severity could affect functional outcomes and the trajectory of recovery. LEVEL OF EVIDENCE: Level III, therapeutic study.

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Background: Understanding the recovery trajectory following operative management of ankle fractures can help surgeons guide patient expectations. Further, it is beneficial to consider the impact of mental health on the recovery trajectory. Our study aimed to address the paucity of literature focused on understanding the recovery trajectory following surgery for ankle fractures, including in patients with depressive symptoms. Methods: From February 2015 to March 2020, patients with isolated ankle fractures were asked to complete Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression questionnaires as part of routine care at presentation and follow-up time points. Linear mixed effects regression models were used to evaluate the patient recovery pattern, comparing the preoperative time point to <3 months, 3-6 months, and >6 months across all patients. Additional models that included the presence of depression symptoms as a covariate were then used. Results: A total of 153 patients met inclusion criteria. By 3-6 months, PROMIS PF (ß: 9.95, 95% CI: 7.97-11.94, P < .001), PI (ß: -10.30, 95% CI: -11.87 to -8.72, P < .001), and Depression (ß: -5.60, 95% CI: -7.01 to -4.20, P < .001) improved relative to the preoperative time point. This level of recovery was sustained thereafter. When incorporating depressive symptoms into our model as a covariate, the moderate to high depressive symptoms were associated with significantly and clinically important worse PROMIS PF (ß: -4.00, 95% CI: -7.00 to -1.00, P = .01) and PI (ß: 3.16, 95% CI: -0.55 to 5.76, P = .02) scores. Conclusion: Following ankle fracture surgery, all patients tend to clinically improve by 3-6 months postoperatively and then continue to appreciate this clinical improvement. Although patients with moderate to high depressive symptoms also clinically improve following the same trajectory, they tend to do so to a lesser level than those who have low depressive symptoms. Level of Evidence: Level III, case-control study.

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IMPORTANCE: The Medicare Bundled Payments for Care Improvement (BPCI) model 3 of 2013 holds participating skilled nursing facilities (SNFs) responsible for all episode costs. There is limited evidence regarding SNF-specific outcomes associated with BPCI. OBJECTIVE: To examine the association between SNF BPCI participation and patient outcomes and across-facility differences in these outcomes among Medicare beneficiaries undergoing lower extremity joint replacement (LEJR). DESIGN, SETTING, AND PARTICIPANTS: Observational difference-in-differences (DID) study of 2013-2017 for 330 unique persistent-participating SNFs, 146 unique dropout SNFs, and 14,028 unique eligible nonparticipating SNFs. MAIN OUTCOME MEASURES: Rehospitalization within 30 and 90 days after SNF admission, and rate of successful discharge from the SNF to the community. RESULTS: Total 636,355 SNF admissions after LEJR procedures were identified for 582,766 Medicare patients [mean (SD) age, 76.81 (9.26) y; 424,076 (72.77%) women]. The DID analysis showed that for persistent-enrollment SNFs, no BPCI-related changes were found in readmission and successful community discharge rates overall, but were found for their subgroups. Specifically, under BPCI, the 30-day readmission rate decreased by 2.19 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, and by 1.75 percentage-points for non-Medicaid-dependent SNFs in the persistent-participating group relative to those in the nonparticipating group; and the rate of successful community discharge increased by 4.44 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, whereas such relationship was not detected among non-White-serving SNFs, leading to increased between-facility differences (differential DID=-7.62). BPCI was not associated with readmission or successful community discharge rates for dropout SNFs, overall, or in subgroup analyses. CONCLUSIONS: Among Medicare patients receiving LEJR, BPCI was associated with improved outcomes for White-serving/non-Medicaid-dependent SNFs but not for other SNFs, which did not help reduce or could even worsen the between-facility differences.

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BACKGROUND: Current literature describing the riskiness of operating on actively infected COVID-19 patients far outnumbers that on the risk of operating on recovered patients. The purpose of this study was to analyze a single, tertiary referral center experience regarding postoperative complications and readmissions in COVID-19-recovered patients versus COVID-19-naïve (never previously infected) patients undergoing elective and emergency surgery across all surgical subspecialties. METHODS: All PCR positive COVID-19 patients that underwent a surgical procedure between February 1, 2020, and November 1, 2020, were included in the COVID-positive cohort. These patients were then matched to COVID-naïve controls that underwent similar procedures within the same time frame. Primary outcomes included 30-day postoperative complications as well as 90-day readmissions. Multivariable analyses were also performed. RESULTS: 112 COVID-positive patients met inclusion criteria and were all matched to COVID-naïve controls. 76 patients (68%) underwent surgery > 30 days from their COVID diagnosis. COVID-positive patients were at significantly higher risk of 30-day complications compared to the COVID-naïve cohort (22% versus 8%, respectively; p < 0.01). Multivariable analyses found ambulatory/asymptomatic infections, undergoing surgery between 30 and 120 days from diagnosis, initial presentation to the emergency department and elevated ASA scores to be significantly associated with 30-day complications. No differences were found for 90-day readmissions. CONCLUSION: Patients with previous COVID-19 infections carry a higher perioperative risk profile for 30-day complications compared to COVID-naïve counterparts in unvaccinated populations.

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Medicare implemented Bundled Payments for Care Improvement (BPCI) Model 3 in 2013, in which participating skilled nursing facilities (SNFs) were accountable for episode costs. We performed comparative interrupted time series analyses to evaluate associations between SNF BPCI participation and nurse staffing levels, using Medicare claims, resident assessments, and facility-level and market-level files of 2010-2017. For persistent-participating SNFs, BPCI was associated with improved certified nursing assistant (CNA) staffing levels (differential change = .03 hours, p = .025). However, BPCI was not related to changes in registered nurse (RN) and all licensed nurse hours, and nurse skill mix. Among drop-out SNFs, BPCI was associated with increased RN staffing levels (differential change = .02 hours, p = .009), leading to a higher nurse skill ratio (0.51 percentage points, p = .016) than control SNFs. Bundled payments for care improvement had no impact on CNA and all licensed nurse staffing levels. In conclusion, BPCI was associated with statistically significant but small increases in nurse staffing levels.

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