RESUMO
BACKGROUND: The prevalence of total joint arthroplasty (TJA) in the United States has drawn the attention of health care stakeholders. The payers have also used a variety of strategies to regulate the medical necessity of these procedures. The purpose of this study was to examine the level of evidence of the coverage policies being used by commercial payers in the United States. METHODS: The references of the coverage policies of four commercial insurance companies were reviewed for type of document, level of evidence, applicability to a TJA population, and success of nonoperative treatment in patients with severe degenerative joint disease. RESULTS: 282 documents were reviewed. 45.8% were primary journal articles, 14.2% were level I or II, 41.2% were applicable to patients who were candidates for TJA, and 9.9% discussed the success of nonoperative treatment in patients who would be candidates for TJA. CONCLUSION: Most of the references cited by commercial payers are of a lower level of scientific evidence and not applicable to patients considered to be candidates for TJA. This is relatively uniform across the reviewed payers. The dearth of high-quality literature cited by commercial payers reflects the lack of evidence and difficulty in conducting high level studies on the outcomes of nonoperative versus operative treatment for patients with severe, symptomatic osteoarthritis. Patients, surgeons, and payers would all benefit from such studies and we encourage professional societies to strive toward that end through multicenter collaboration.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Humanos , Políticas , Estados UnidosRESUMO
BACKGROUND: Concerns exist that minorities who utilize more resources in an episode-of-care following total hip (THA) and knee arthroplasty (TKA) may face difficulties with access to quality arthroplasty care in bundled payment programs. The purpose of this study is to determine if African American patients undergoing TKA or THA have higher episode-of-care costs compared to Caucasian patients. METHODS: We queried Medicare claims data for a consecutive series of 7310 primary TKA and THA patients at our institution from 2015 to 2018. We compared patient demographics, comorbidities, readmissions, and 90-day episode-of-care costs between African American and Caucasian patients. A multivariate regression analysis was performed to identify the independent effect of race on episode-of-care costs. RESULTS: Compared to Caucasians, African Americans were younger, but had higher rates of pulmonary disease and diabetes. African American patients had increased rates of discharge to a rehabilitation facility (20% vs 13%, P < .001), with higher subacute rehabilitation ($1909 vs $1284, P < .001), home health ($819 vs $698, P = .022), post-acute care ($5656 vs $4961, P = .008), and overall 90-day episode-of-care costs ($19,457 vs $18,694, P = .001). When controlling for confounding comorbidities, African American race was associated with higher episode-of-care costs of $440 (P < .001). CONCLUSION: African American patients have increased episode-of-care costs following THA and TKA when compared to Caucasian patients, mainly due to increased rates of home health and rehabilitation utilization. Further study is needed to identify social variables that can help reduce post-acute care resources and prevent reduction in access to arthroplasty care in bundled payment models.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Negro ou Afro-Americano , Idoso , Humanos , Medicare , Readmissão do Paciente , Cuidados Semi-Intensivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The process of infection and multiple procedure-related factors in 2-stage exchange arthroplasty may lead to severe bone loss that can complicate subsequent reimplantation. The primary purpose of this study is to quantitatively characterize the extent of bone loss on the femoral and acetabular side prior to reimplantation during 2-stage revision hip arthroplasty for infection. METHODS: This retrospective case series includes 47 patients with planned 2-stage exchange arthroplasty for treatment of infected total hip replacement. Demographic, clinical, and surgical information, and complications during the 2-stage process were collected on all patients. The radiographs of all patients were reviewed prior to first-stage explantation and post-reimplantation or latest follow-up to characterize bone loss using the Paprosky classification systems. RESULTS: Of the 47 patients with planned 2-stage exchange, 10 patients (21%) were not reimplanted. Following explant and spacer placement, 32 patients (68%) experienced progressive femoral bone loss, and 20 (43%) experienced progressive acetabular bone loss. Patients who experienced progression of both femoral and acetabular bone (14, 30%) had a longer time between resection and reimplantation (164 ± 128 vs 88 ± 26 days, P = .03). A reimplantation time of greater than 90 days was associated with an increased risk of combined bone loss progression (15% vs 53%, P = .01). For patients who underwent reimplantation (79%), increased bone loss led to high rates of diaphyseal femoral fixation (97%) and revision acetabular components (38%). CONCLUSION: Increased time to reimplantation in 2-stage exchange arthroplasty for prosthetic hip infections is associated with a high rate of acetabular and femoral bone loss, and increased complexity of reimplantation.
Assuntos
Artroplastia de Quadril , Prótese de Quadril , Acetábulo/diagnóstico por imagem , Acetábulo/cirurgia , Artroplastia de Quadril/efeitos adversos , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Prótese de Quadril/efeitos adversos , Humanos , Reoperação , Estudos RetrospectivosRESUMO
BACKGROUND: With the increasing popularity of alternative payment models, minorities who use more postacute care resources may face difficulties with access to quality total hip arthroplasty (THA) and total knee arthroplasty (TKA) care. The purpose of this study is to compare differences in perioperative complications and functional outcomes between African American and Caucasian patients undergoing THA and TKA. METHODS: We reviewed a consecutive series of all primary THA and TKA patients at our institution from 2015 to 2018. Demographics, comorbidities, 90-day complications, readmissions, Veterans Rand 12-Item Health Survey (VR-12), Hip disability Osteoarthritis Outcome Score (HOOS), and Knee injury and Osteoarthritis Outcome Scores (KOOS) were compared between African American and Caucasian patients. A multivariate analysis was performed to control for confounding variables. RESULTS: Of the 5284 patients included in the study, 1041 were African American (24.5%). Although African American patients had lower preoperative HOOS/KOOS (33.5 vs 45.1, P < .001) and mental VR-12 scores (37.8 vs 51.5, P < .001) compared with Caucasian patients, there was no clinical difference at 1 year in HOOS/KOOS (50.2 vs 50.4), mental VR-12 (55.0 vs 52.6), or physical VR-12 scores (39.5 vs 39.8). When controlling for demographics and medical comorbidities, African American race was associated with increased rehabilitation facility discharge (odds ratio, 1.69; P < .001) but no difference in readmissions or complications. CONCLUSION: Although African American patients had lower preoperative functional scores, they made improved postoperative gains when compared with Caucasian patients. Although there was no difference in postoperative complications, further studies should assess social causes for the increase in rehabilitation utilization rates in minority patients.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Osteoartrite do Quadril , Negro ou Afro-Americano , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Humanos , Osteoartrite do Quadril/cirurgia , População BrancaRESUMO
INTRODUCTION: Studies have shown that patients with diabetes mellitus are at an increased risk for complications and higher episode-of-care costs after total hip (THA) and total knee arthroplasties (TKA), but the effect of poor glycemic control on episode-of-care costs has yet to be addressed in the literature. The purpose of this study was to determine whether patients with a higher preoperative hemoglobin A1c have increased episode-of-care costs in diabetic patients undergoing THA and TKA. METHODS: We reviewed a consecutive series of 9,511 primary THA and TKA patients between 2015 and 2018. We recorded demographics, medical comorbidities, and hemoglobin A1c for patients with diabetes mellitus. We compared complications, readmissions, and 90-day episode-of-care costs from Medicare claims data across A1c levels. A multivariate logistic regression analysis was done to assess the independent effect of A1c on episode-of-care costs. RESULTS: Diabetic patients (n = 1,042) had higher episode-of-care costs ($20,577 vs $19,414, P < 0.001) than patients without diabetes. Higher stratified A1c levels were associated with increasing mean episode-of-care costs (6.5% to 6.9% = $18,912; 7.0% to 7.49% = $19,832; 7.5% to 7.9% = $20,827; >8% = $21,169). In multivariate analysis, patients with hemoglobin A1c >7.5% had higher episode-of-care costs ($2,331, 95% confidence interval, $511-$4,151, P = 0.012). Those with a hemoglobin A1c >7.5% had increased rates of complications (7% vs 3%, P = 0.049) and readmissions (11% vs 5%, P = 0.020). DISCUSSION: Hemoglobin A1c levels above 7.5% are associated with increased episode-of-care costs, complications, and readmissions after THA and TKA. Optimizing glycemic control before surgery may improve quality of care and lead to success in Medicare bundled payment models.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Idoso , Custos e Análise de Custo , Hemoglobinas Glicadas , Humanos , Medicare , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Implementation of rapid recovery protocols and value-based programs in total joint arthroplasty (TJA) has required changes in preoperative management, such as optimization, education, and coordination. This study aimed to quantify the work burden associated with preoperative TJA care. METHODS: Two web-based surveys were distributed to surgeon members of the American Association of Hip and Knee Surgeons. The first questionnaire (265 respondents) consisted of questions related to preoperative patient care in TJA and the associated work burden by orthopedic surgeons and their financially dependent health care providers. The second survey (561 respondents) consisted of questions related to relative change in preoperative patient care work burden since 2013. RESULTS: Greater than 98% of survey respondents reported providing some level of preoperative medical optimization to their patients. The mean amount of reported time spent by the surgeon and/or a qualified health care provider in preoperative activities not included in work captured in current procedural terminology or hospital billing codes was 153 minutes. The mean amount of reported time spent by ancillary clinical staff in preoperative activities was 177 minutes. Most surgeons reported an increase in work burden for total knee (86%) and total hip (87%) arthroplasty since 2013, with a large portion reporting a 20% or greater increase in work (knee 66%, hip 64%). CONCLUSION: To provide quality arthroplasty care with marked reductions in complication rates, lengths of stay, and readmissions, members of the American Association of Hip and Knee Surgeons report a substantial preoperative work burden that is not included in current coding metrics. Policy makers should account for this time in coding models to continue to promote pathway improvements.