Search

Background: The purpose of this study is to define value in bundled total joint arthroplasty (TJA) from the differing perspectives of the patient, payer/employer, and hospital/provider.Methods: Demographic, psychosocial, clinical, financial, and patient-reported outcomes (PROs) data from 2017 to 2018 elective TJA cases at a multihospital academic health system were queried. Value was defined as improvement in PROs (preoperatively to 1 year postoperatively) for patients, improvement in PROs per $1000 of bundle cost for payers, and the normalized sum of improvement in PROs and hospital bundle margin for providers. Bivariate analysis was used to compare high value vs low value (>50th percentile vs <50th percentile). Multivariate analysis was performed to identify predictors.Results: A total of 280 patients had PRO data, of which 71 had Medicare claims data. Diabetes (odds ratio [OR], 0.45; P = .02) predicted low value for patients; female gender (OR, 0.25), hypertension (OR, 0.17), pulmonary disease (OR, 0.12), and skilled nursing facility discharge (OR, 0.17) for payers (P ≤ .03 for all); and pulmonary disease (OR, 0.16) and skilled nursing facility discharge (OR, 0.19) for providers (P ≤ .04 for all).Conclusion: This is the first article to define value in TJA under a bundle payment model from multiple perspectives, providing a foundation for future studies analyzing value-based TJA. [ABSTRACT FROM AUTHOR]

Purpose: Patient-reported outcomes measures (PROMs) such as PROMIS are increasingly utilized in healthcare to assess patient perception and functional status, but the effect of delivery setting remains to be fully investigated. To our knowledge, no current study establishes the absence of differential item functioning (DIF) across delivery setting for these PROMIS- Global Health (PROMIS-GH) measures among orthopedic patients. We sought to investigate the correlation of PROMIS-GH scores across in-clinic versus remote delivery by evaluating DIF within the Global Physical Health (GPH) and Global Mental Health (GMH) items. We hypothesize that the setting of delivery of the GPH and GMH domains of PROMIS-GH will not impact the results of the measure, allowing direct comparison between the two delivery settings. Methods: Five thousand and seven hundred and eighty-five complete PROMIS-Global Health measures were analyzed retrospectively using the 'Lordif' package on the R platform. DIF was measured for GPH and GMH domains across setting of response (in-clinic vs remote) during the pre-operative period, immediate post-operative period, and 1-year post-operative period using Monte Carlo estimation. McFadden pseudo-R2 thresholds (> 0.02) were used to assess the magnitude of DIF for individual PROMIS items. Results: No GPH or GMH items contained in the PROMIS-GH instrument yielded DIF across in-clinic vs remote delivery setting during the pre-operative, immediate post-operative, or 1-year post-operative window. Conclusion: The GPH and GMH domains within the PROMIS-GH instrument may be delivered in the clinic or remotely with comparable accuracy. This cross-delivery setting validation analysis may aid to improve the quality of patient care by allowing mixed platform PROMIS-GH data tailored to individual patient circumstance. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the functioning of the PROMIS-Global Health (PROMIS-GH) across clinical setting, patient age, and medical complexity by evaluating differential item functioning (DIF) within the Global Physical Health (GPH) and Global Mental Health (GMH) domains. To our knowledge, no study demonstrates lack of differential item functioning (DIF) for PROMIS-GH across these populations. We hypothesize that the PROMIS-GH domains of GMH and GPH will perform similarly when compared across these populations. Methods: Seven thousand nine hundred and seventy four complete PROMIS Global Health measures were retrospectively analyzed using the 'Lordif' package on the R platform. DIF was investigated for both GMH and GPH across clinical environment (Orthopedic Surgery, Family Medicine, & Internal Medicine), age group (≤ 53, > 53–66, > 66), and Charlson Comorbidity Index (CCI:0, CCI:1, CCI:2 +) using quasi Monte Carlo estimation. To assess the significance of DIF, Wald tests were used with the Benjamini & Hochberg procedure. Results: No items contained in the GMH or GPH demonstrated DIF across age groups, medical complexity, or clinical environment. Conclusion: Items assessing the domains of GMH and GPH within the PROMIS–GH function comparably across treatment setting, age category, and medical comorbidities. The PROMIS–Global Health holds potential to facilitate interdisciplinary patient care and patient optimization prior to surgical intervention. [ABSTRACT FROM AUTHOR]

Background: Ambulatory surgery centers (ASCs) are increasingly replacing traditional hospital settings for orthopaedic procedures, driven by advancements in surgical techniques, anesthesia, and enhanced recovery protocols. These innovations enable complex procedures to be performed safely in outpatient settings. ASCs align with value-based care (VBC) principles by offering cost-effective, high-quality, and patient-centered care. This article explores strategies to integrate VBC into ASCs, focusing on operational, financial, and clinical enhancements., Methods: This analysis evaluates strategies for preparing ASCs for alternative payment models (APMs) like bundled payments and Accountable Care Organizations. It highlights the importance of standardizing practices, such as lean methodologies and Six Sigma approaches, to improve efficiency and outcomes. Data collection is targeted at actionable metrics, and cost management includes strategies like standardized implant selection and vendor negotiations. Financial alignment through performance-based compensation structures was also assessed., Results: ASCs have demonstrated cost savings of up to 45% compared to hospital outpatient departments, driven by streamlined operations and patient-centric approaches. Adopting APMs fosters improved care coordination and efficiency while aligning financial incentives with clinical outcomes. Standardizing practices, such as implant selection and clinical protocols, has reduced variability, enhanced surgical outcomes, and controlled costs. Performance monitoring using metrics like patient-reported outcome measures and surgical complication rates has facilitated continuous improvement., Conclusions: ASCs represent a significant opportunity to implement VBC principles in orthopaedic surgery. By preparing for APMs, standardizing practices, and leveraging performance data, ASCs can achieve cost savings and improve patient outcomes. Continuous improvement and alignment between financial and clinical goals are essential for ASCs to remain leaders in orthopaedic care delivery. These strategies position ASCs to meet the evolving demands of health care while maintaining high-quality, patient-centered care., (Copyright © 2024. Published by Elsevier Inc.)

Background: The health care system is transitioning from fee-for-service models to value-based care frameworks, with bundled payments emerging as a promising approach to improve cost efficiency and patient outcomes. Bundled payments consolidate costs for multiple services into a single payment for specific treatments or conditions. This study reviews the development and implementation of bundling models in orthopaedics, comparing government and commercial approaches and discussing their benefits and challenges., Methods: A review of the literature was conducted to examine existing bundling programs in orthopaedics, including Medicare initiatives like the Bundled Payments for Care Improvement and Comprehensive Care for Joint Replacement model, as well as commercial programs from insurers such as Cigna and UnitedHealthcare. The review focused on published studies, reports, and case examples to identify trends, outcomes, and barriers associated with these models., Results: Government programs such as Comprehensive Care for Joint Replacement have demonstrated improved care coordination and cost control but face challenges in engaging physicians and aligning financial incentives. Commercial models, with greater flexibility in their prospective payment structures, allow for customization and better financial predictability but require careful negotiation and compliance with quality metrics. Both approaches highlight the importance of robust data management, multidisciplinary collaboration, and innovative partnerships to improve care delivery. Condition-based bundling, though conceptually aligned with value-based care, remains in its early stages within orthopaedics., Conclusions: Bundled payment models represent a key strategy for advancing sustainable and efficient health care delivery in orthopaedics. Despite challenges like stakeholder alignment and resource demands, these models offer potential to enhance care quality and reduce costs. Future directions should prioritize collaboration, technology integration, and the resolution of implementation barriers to fully realize the benefits of bundling in orthopaedic practices., (Copyright © 2024. Published by Elsevier Inc.)

Competing Interests: The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Abstract: The dynamic health-care environment continues to undergo disruptive change. As the health-care system emerges from the pandemic, underlying issues have progressively become critical. Private equity acquisition is dramatically increasing, and consolidation in the entire health-care system limits choice and access. Challenges in the workforce and supply chain persist, adding pressure on already strained health-care organizations. Innovative solutions are required to provide equitable value-based access to orthopaedic care., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H850 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The coronoavirus disease 2019 (COVID-19) pandemic had profound impact on elective procedures in the United States. We characterized the longer-term decline and recovery of hip and knee arthroplasty procedures following the onset of the COVID-19 pandemic in the United States., Methods: We conducted a retrospective analysis of patients undergoing primary and revision total knee and hip arthroplasty (TKA and THA) in the United States between 2014 and 2020 using claims from a large national commercial payer data set contaivning deidentified information from patients with commercial health coverage. We calculated the percentage of cases lost by month using a forecast model to predict TKA and THA volumes in the absence of COVID-19. We then calculated the association between COVID-19 positivity rates and THA/TKA procedures by state and month., Results: There was a large initial decline in procedures, with primary TKA and THA volumes declining by 93.2% and 87.1% in April 2020, respectively, with revisions seeing more modest declines. Cases quickly recovered with volumes exceeding expected levels in summer months. However, cumulative 2020 volumes remained below expected with 9.7% and 7.5% of expected primary TKA and THA cases lost, respectively. Higher state COVID-19 positivity rates were associated with lower primary TKA, THA, and revision knee procedure rates., Conclusions: After the initial decline in March and April, knee and hip arthroplasty cases resumed quickly; however, by the end of 2020, the annual procedure volume had still not recovered fully. The loss in case volume within states was worse in months with higher COVID-19 positivity rates., (© 2024 The Authors.)

Background: A shift toward performance, cost, outcomes, and patient satisfaction has occurred with healthcare reform promoting value-based programs. The purpose of this study was to evaluate the relationship between patient satisfaction and value with treatment in a cohort of patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA)., Methods: Value was determined by the relationship of treatment outcome with episodic cost. Measurements included both clinical outcomes and patient-reported outcomes. Participating surgeons took part in the modified Delphi method resulting in an algorithm measuring patient value. Treatment outcome, cost, and resultant value (outcome/cost) of both TKA and THA were evaluated using binomial logistic regression by adjusting for age, gender, body mass index, Charlson comorbidity index, tobacco, education, and income with patient-reported satisfaction as the outcome., Results: This study had a total of 909 patients (TKA n = 438; THA n = 471), with an average age of 67 (TKA) and 65 (THA) years. Patient satisfaction shared a significant positive relationship with treatment outcome for TKA (odds ratio [OR] = 1.53, confidence interval [CI] = 1.35-1.73, P < .001) and THA (OR = 1.93, CI = 1.62-2.29, P < .001). Higher value was associated with a significantly higher odds of patient satisfaction for both TKA (OR = 1.39, CI = 1.25-1.54, P < .001) and THA (OR = 1.70, CI = 1.47-1.97, P < .001)., Conclusions: This study showed a positive relationship between treatment outcome but not cost with subsequent value and patient satisfaction. This method provides a promising approach to comprehensively evaluate outcomes, cost, and value of total joint arthroplasty procedures. This approach can help predict the probability of value-driven patient satisfaction.

Objective: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA)., Methods: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations., Results: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality., Conclusion: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations., (Copyright © 2023 American Association of Hip and Knee Surgeons, American College of Rheumatology. Published by Elsevier Inc. All rights reserved.)

Background: There is debate regarding the efficacy of intra-articular (IA) hyaluronic acid (HA) injections for the management of knee osteoarthritis (OA). This study aimed to determine if IA HA utilization and payer coverage of viscosupplementation affected the prevalence of total knee arthroplasty (TKA) procedures and the age of TKA patients., Methods: We performed a retrospective analysis from 2014 to 2020 using a large national commercial claims data set. We analyzed the number of TKA procedures and the age of the patients in states that covered IA HA vs those with limited coverage. Mixed random effects and slopes models were used to identify the impact of the IA HA injections., Results: Of 7,335,301 patients with knee OA, 440,606 (6.0%) received a TKA procedure at an average age of 59 years. The rate of TKA procedures increased by 0.56% per year (95% confidence interval [CI] 0.46-0.66; P < .001). Payer coverage of IA HA injections had no effect on TKA prevalence ( P  = .926). The age of surgical patients increased yearly by 0.15 years (95% CI 0.12-0.18; P < .001), regardless of IA HA injections ( P  = .990). After controlling for demographics and comorbidities, patients that received an IA HA injection had a higher probability of receiving a subsequent TKA (odds ratio = 2.83; 95% CI 2.80-2.87; P < .001); this finding was conditional of patients' age at the first diagnosis of knee OA., Conclusions: Additional clinical trials should be employed to identify the role of HA injections in the treatment armamentarium for knee OA., (© 2022 The Authors.)

Background: Total knee arthroplasty (TKA) is 1 of the top 2 most common and expensive surgical procedures among Medicare beneficiaries. Due to the procedure's high annual cost, overdiagnosis and subsequent overutilization of TKA has substantial health-policy implications. Concerns regarding the overexaggeration of radiographic findings and overutilization of TKA have been expressed by medical insurers. Currently, the standard of care for assessing potential knee arthroplasty candidates includes assigning a Kellgren-Lawrence (KL) radiographic score. Our study investigated the accuracy of reported preoperative KL scores in patients undergoing TKA., Material and Methods: Records of 277 patients who had underwent TKA at our institution for knee osteoarthritis were randomly selected from a large patient data registry and retrospectively reviewed. Two blinded raters assigned KL scores to the radiographs obtained during the preoperative assessment, which were compared to the scores reported by the operative surgeon. An intraclass correlation coefficient (ICC) was calculated to determine inter-rater reliability., Results: Between blinded raters, ICC 3k  = 0.88 (95% confidence interval: 0.86-0.90, P < .001), demonstrating good reliability. Between all raters, ICC 2k  = 0.89 (95% confidence interval: 0.86-0.90, P < .001), also demonstrating good agreement. Raters fully agreed on the KL classification for 196 patients (70.76%). Compared with blinded raters, the operative surgeon assigned lower KL scores., Conclusion: Reporting of KL score is consistent between operative surgeons and independent reviewers. In cases of disagreement between reviewers, the operative surgeon was generally more conservative in their estimation of the extent of osteoarthritis present radiographically. Concerns regarding inflation of radiographic findings to support surgical preauthorization are unwarranted., (© 2022 The Authors.)

Background: Web-based patient engagement portals are increasing in popularity after total hip and knee arthroplasty (THA and TKA). The literature is mixed regarding patient utilization of these modalities and potential clinical benefit. We sought to determine which demographic factors are associated with increased platform participation and to quantify the impact of a web-based patient portal on patient-reported outcome measures (PROMs)., Methods: We performed a retrospective analysis of consecutive primary THA (n = 554) and TKA (n = 485) at a single academic institution with minimum follow-up of 12 months. Patients were divided into those who opted-in and those who opted-out of portal use. Global health and joint-specific PROMs were collected preoperatively and postoperatively. Linear mixed effects modeling, bivariate analysis, and logistic regression were utilized., Results: Of the 1039 included patients, 60.6% (336) THA and 62.7% (304) TKA patients enrolled in the portal. Those who opted-in were younger (P < .001, P < .003), had higher body mass index (P = .024, P = .011), and had a higher household income (P < .001, P < .001) in THA and TKA cohorts, respectively. Portal participation in the TKA but not the THA cohort was associated with significant improvement in physical function (P = .017) and joint-specific function (P = .045). For THA patients who opted-in, increased portal logins were associated with more rapid improvement and higher functional scores (P = .013)., Conclusion: There is an inherent difference between patients who opt-in to and those who opt-out of web-based portals. Added resources and support provided by portals may translate to improved PROMs for TKA patients but not THA patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Given financial and clinical implications of readmissions after total hip arthroplasty (THA) and the potential for varied expenditures related to a hospital's teaching status, this study sought to characterize 90-day hospital readmission patterns and assess likelihood of readmission based on teaching designation of a Medicare beneficiaries' (MB's) index THA hospital., Methods: Retrospective analysis of 2016-2018 Centers for Medicare and Medicaid Services-linked data identified primary THA hospitalizations and readmissions within 90 days. Hospitals were categorized as teaching or nonteaching (Council of Teaching Hospitals and Health Systems). Chi-squared analysis and Fisher exact test assessed differences between readmission hospitals and the index hospital teaching status. Multivariate logistic regression models estimated risk-adjusted probability of experiencing at least one 90-day readmission., Results: Analysis identified 433,959 index THA admissions with an all-cause 90-day readmission rate of 9.12%. Most readmissions were to the same hospital regardless of index THA hospital teaching status (67.5% index teaching; 68.2% index nonteaching). Crossover in hospital teaching status from the index procedure to readmission location was more common for those with index THA at a teaching hospital (18.9%) than for MBs with index THA performed at a nonteaching hospital (6.2%). Controlling for patient characteristics, no significant relationship was found between 90-day readmission and index hospital teaching status (odds ratio 0.98, confidence interval 0.947-1.011)., Conclusions: Overall, while certain patterns of readmission after the index THA were observed, after controlling for patient characters and comorbidities, there was no significant association between 90-day all-cause readmission and index hospital teaching status., (© 2021 The Authors.)

Background: Risk-factor identification related to chronic opioid use after surgery may facilitate interventions mitigating postoperative opioid consumption. We evaluated the relationship between opioid use preceding total hip arthroplasty (THA) and total knee arthroplasty (TKA), and chronic use postoperatively, and the risk of chronic opioid use after total joint arthroplasty., Methods: All primary THAs and TKAs performed during a 6-month period were identified. Opioid prescription and utilization data (in oxycodone equivalents) were determined via survey and electronic records. Relationship between preoperative opioid use and continued use >90 days after surgery was assessed via Chi-square, with significance set at P < .05., Results: A total of 415 patients met inclusion criteria (240 THAs and 175 TKAs). Of the 240 THAs, 199 (82.9%) patients and of the 175 TKAs, 144 (82.3%) patients agreed to participate. Forty-three of 199 (21.6%) THA patients and 22 of 144 (15.3%) TKA patients used opioids within 30 days preoperatively. Nine of 199 (4.5%) THA and 10 of 144 (6.9%) TKA patients had continued use of opioids for >90 days postoperatively. Preoperative opioid consumption was significantly associated with chronic use postoperatively for THA ( P  = .011) and TKA ( P  = .024). Five of 43 (11.6%) THA and 4 of 22 (18.2%) TKA patients with preoperative opioid use had continued use for >90 days postoperatively. For opioid naïve patients, 2.6% (4/156) of THA and 4.9% (6/122) of TKA patients had chronic use postoperatively., Conclusions: Preoperative opioid use was associated with nearly 5-fold and 4-fold increase in percentage of patients with chronic opioid use after THA and TKA, respectively. Surgeons should counsel patients regarding this risk and consider strategies to eliminate preoperative opioid use., (© 2021 The Authors.)

Background: Perioperative antibiotic prophylaxis is used to prevent surgical site infection and periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). Secondary to a national shortage of cefazolin, patients at our institution began receiving a single preoperative prophylactic antibiotic dose for primary TJA and no 24-hour postoperative antibiotic prophylaxis. The purpose of the study was to compare the efficacy of single-dose antibiotic use versus 24-hour dosing of prophylactic antibiotics in the prevention of acute PJI and short-term complications after primary TJA., Methods: A retrospective review of 3317 patients undergoing primary TJA performed from January 2015 to December 2019 identified 554 patients who received a single dose of preoperative antibiotic prophylaxis during the antibiotic shortage and 2763 patients who received post-TJA 24-hour antibiotic prophylaxis before the shortage. Patient records were evaluated for acute PJI, superficial infection, 90-day reoperation, and 90-day complications., Results: There were no significant differences in patient characteristics between single-dose and 24-hour antibiotic groups. Similarly, there were no significant differences in rates of acute PJI (0.7% vs 0.2%; P = .301), superficial infection (2.4% vs 1.4%; P = .221), 90-day reoperation (2.1% vs 1.1%; P = .155), and 90-day complications (9.9% vs 7.9%; P = .169) between single and 24-hour antibiotic dose. Post hoc power analysis demonstrated adequate sample size, beta = 93%., Conclusion: Single-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. Our study suggests that administration of a single antibiotic dose may be safely considered in patients undergoing routine primary TJA., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Patients with mood disorders undergoing total joint arthroplasty (TJA) are at increased risk for poor outcomes. This study seeks to examine the effect of anxiety disorders on pain following TJA and evaluate if anxiety disorders are a modifiable risk factor., Methods: Between March 2019 and July 2020, 319 TJA patients had preoperative anxiety screening using the Generalized Anxiety Disorder 2-item screening tool (GAD-2) and 6-week postoperative Pain Catastrophizing Scale scores. Patients were organized into 4 cohorts based on preoperative selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) use and GAD-2 scores: Group 1: no SSRI/SNRI use and GAD-2 score <3 (control patients); Group 2: SSRI/SNRI use and GAD-2 score <3 (appropriately treated GAD patients); Group 3: no SSRI/SNRI use and GAD-2 score ≥3 (untreated GAD patients); and Group 4: SSRI/SNRI use and GAD-2 score ≥3 (poorly treated GAD patients). The cohorts underwent multivariate linear regression analysis and equivalence testing., Results: Patients with preoperative GAD-2 scores ≥3 had worse postoperative pain with significantly higher average 6-week postoperative Pain Catastrophizing Scale score than patients with GAD-2 scores <3 (9.90 vs 5.19, P < .001). Patients with appropriately treated GAD and the control group had statistically equivalent postoperative pain, while patients with poorly treated or untreated GAD had worse postoperative pain., Conclusion: Preoperative GAD is a risk factor for poor postoperative pain control but is a modifiable risk factor when patients are appropriately treated. Screening for preoperative GAD with GAD-2 and referral for treatment may improve patient outcomes and reduce opioid consumption following TJA., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: There is focus on the direct anterior approach (DAA) for total hip arthroplasty because of perceived postoperative functional improvement. We compared baseline, short-term, and long-term outcomes between the DAA and the posterior approach focusing on baseline function., Material and Methods: Multivariate linear and logistic regression models were used to analyze prospective data on 1457 total hip arthroplasties comparing baseline characteristics, operative time, 90-day reoperation, length of stay (LOS), extended LOS (>3 days), and facility discharge. The Patient-Reported Outcome Measurement Information System-Global Health (PROMIS-10) was used to determine physical component score (PCS) and mental component score (MCS), with clinically significant improvement defined as >5 points. Adjusters included age, sex, race/ethnicity, year, Charlson Comorbidity Index, body mass index, alcohol, and tobacco use., Results: DAA patients had higher preoperative MCS (DAA 50.4 vs posterior approach 47.4, P < .001), PCS (40.7 vs 38.5, P < .001), and postoperative PCS scores (48.9 vs 46.7, P < .001). There was no difference in mean PCS improvement (8.1 vs 8.2; P  = .798) or clinically significant PCS change ( P  = .963). DAA was associated with shorter LOS by 0.49 days (95% confidence interval [CI] = 0.32-0.65, P < .001), lower odds of extended LOS (odds ratio = 0.33, 95% CI = 0.21-0.50, P < .001), and lower odds of facility discharge (odds ratio = 0.54, 95% CI = 0.37-0.79, P < .001). No difference in operative time (86 vs 87 minutes; P  = .812) or 90-day reoperations (1 vs 1%; P  = .347) was observed., Conclusion: DAA patients presented with higher preoperative PCS and MCS scores, yet both groups experienced significant improvement. DAA was associated with decreased LOS and lower odds of extended LOS and facility discharge. There was no difference in operative time or reoperation., (© 2021 The Authors.)

Introduction: Traditional physical therapy (PT) requires patients to attend weekly in-office supervised physical therapy appointments. However, between 50% and 70% of patients who would benefit do not receive prescribed PT due to barriers to access. Virtual Reality (VR) provides a platform for remote delivery of PT to address these access barriers., Methods: We developed a VR-PT program consisting of training, games, and a progress dashboard for 3 common lower extremity physical therapy exercises. We enrolled orthopaedic trauma patients with lower extremity injuries. Patients completed a VR-PT session, consisting of training and one of the exercise-based games. Pre- and post-VR-PT questionnaires were completed., Results: We enrolled 15 patients with an average age of 51 years. Fourteen patients said they would enroll in a randomized trial in which they had a 50% chance of receiving VR-PT vs receiving standard of care. When asked to rate their experience using the VR-PT module on a scale from 0-10-with 0 being anchored as "I hated it" and 10 being anchored as "I loved it"-the average rating was 7.5. Patients rated the acceptability of VR-PT as a 3.9 out of 5, the feasibility as a 4.0 out of 5, and the usability as a 67.5 out of 100., Conclusion: The response to VR-PT in this pilot study was positive overall. A VR-based PT program may add value for both patients and clinicians in terms of objective data collection (to aid in compliance monitoring, progression toward goals and exercise safety), increased engagement and increased access., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: Under bundled payment models, gainsharing presents an important mechanism to ensure engagement and reward innovation. We hypothesized that metric selection, metric targets, and risk adjustment would impact surgeons' performance in gainsharing models., Methods: Patients undergoing total joint arthroplasty at an urban health system from 2017 to September 2018 were included. Gainsharing metrics included the following: length of stay, % discharge-to-home, 90-day readmission rate, % of patients with episode spend under target price, and % of patients with patient-reported outcomes (PROs) collected. Four scenarios were created to evaluate how metric selection/adjustment impacted surgeons' performance designation: scenario 1 used "aspirational targets" (>60th percentile), scenario 2 used "acceptable targets" (>50th percentile), scenario 3 risk-adjusted surgeon performance prior to comparing aspirational targets, and scenario 4 included a PRO collection metric. Number of metrics achieved determined performance tier, with higher tiers getting a greater share of the gainsharing pool., Results: In total, 2776 patients treated by 12 surgeons met inclusion criteria (mean length of stay 3.0 days, readmission rate 4.0%, discharge-to-home 74%, episode spend under target price 85%, PRO collection 56%). Lowering of metric targets (scenario 1 vs. 2) resulted in a 75% increase in the number of high performers and 98% of the gainsharing pool being eligible for distribution. Risk adjustment (scenario 3) caused 50% of providers to move to higher performance tiers and potential payments to increase by 28%. Adding the PRO metric did not change performance., Conclusion: Quality metric/target selection and risk adjustment profoundly impact surgeons' performance in gainsharing contracts. This impacts how successful these contracts can be in driving innovation and dis-incentivizing the "cherry picking" of patients., Level of Evidence: Level III., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The novel coronavirus, severe acute respiratory coronavirus 2 (SARS-CoV-2), pandemic has delivered a profound and negative impact on the United States. The suspension of elective surgeries including arthroplasty will have a lasting effect on all stakeholders including patients, physicians, and healthcare organizations within the US healthcare system. Resumption of elective hip and knee arthroplasty will need to be carefully focused. The purpose of this work is to address potential strategies, concerns, and regulatory barriers in restarting elective hip and knee arthroplasty in the United States., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Several patient-reported outcome measures (PROMs) exist to measure outcomes after total hip arthroplasty (THA) but can be limited by patient-perceived burden and completion rates. We analyzed whether the modified single assessment numerical evaluation (M-SANE), a one-question PROM, would perform similarly to multiple-question PROMs among patients undergoing primary THA., Methods: Patients undergoing THA completed the Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10), the Hip Disability and Osteoarthritis Outcomes Score Junior (HOOS-Jr), and M-SANE questionnaires both preoperatively and postoperatively. The M-SANE assessment asked patients to assess their hip on a scale from 0 to 10, with 10 being the best possible score. Validity of M-SANE compared with other PROMs was determined by Spearman's correlation and floor and ceiling effects. Responsiveness was analyzed using standardized response mean (SRM)., Results: One hundred and thirty six patients with at least 1-year follow-up were reviewed. The average M-SANE score improved from 3.3 preoperatively to 7.1 at one year postoperatively. There was moderate to strong correlation at one-year follow-up between the M-SANE and HOOS-Jr (ρ = 0.75, P < .001) and PROMIS-10 physical component summary (ρ = 0.63, P < .001). Floor and ceiling effects of the M-SANE (floor 2.0%, ceiling 21.3%) were comparable to the HOOS-Jr (floor 0.0%, ceiling 20.8%). The responsiveness of the M-SANE after THA (SRM = 1.06, 95% CI: 0.79-1.33) was comparable to HOOS-Jr (SRM = 1.33, 95% CI: 1.08-1.59) and superior to PROMIS-10 physical component summary (SRM = 0.65, 95% CI: 0.55-0.74)., Conclusion: The M-SANE has performed similarly across multiple psychometric properties compared with more burdensome PROMs in assessing longitudinal patient-reported outcomes after THA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: This prospective cohort study evaluates the impact of total hip arthroplasty and total knee arthroplasty on patient's spouses/significant others (SSOs)., Methods: Patients and SSOs were provided similar outcome metrics (Global Health Patient-Reported Outcomes Measurement Information System, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement) at preoperative and postoperative visits. Pearson correlation was used to evaluate scores., Results: Our sample included 99 patients (58 total hip arthroplasties and 41 total knee arthroplasties). We found strong correlation between patient and SSO mental status scores. We found moderate correlation for some physical function domains., Conclusion: SSOs closely share total joint arthroplasty patient's mental and even some of the physical burden of disease and recovery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: This study evaluates the fate of unused opioids after total hip arthroplasty (THA) and total knee arthroplasty (TKA) at our facility., Methods: Medication disposal after primary elective THA and TKA was classified as appropriate (in accordance with United States Food and Drug Administration guidelines) or inappropriate for all patients undergoing these procedures during the second half of the fiscal year 2015., Results: In total, 199 THAs and 144 TKAs met inclusion criteria. Total pills prescribed were 55,635. Approximately 8925 (16%) of pills were unused. About 39.9% of patients disposed of unused opioids appropriately, while 60.1% of patients reported still having (18.5%), not knowing where they were (8.2%), or other (33.4%). There was no significant association with the type of opioid prescribed., Conclusion: A large volume of unused opioids were improperly disposed of after total joint arthroplasty., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The Comprehensive Care for Joint Replacement (CJR) mandates collection of patient-reported outcome measures (PROMs) for eligible total hip and total knee arthroplasty (THA and TKA) procedures during specific time periods that may not be attainable within routine academic practice., Methods: We performed a retrospective analysis of prospectively collected PROM data from a 2017 cohort of primary THA and TKA patients who completed the Patient-Reported Outcomes Measurement Information System-10 global health survey in preoperative or postoperative time periods. The primary outcome was completion rates of Patient-Reported Outcomes Measurement Information System-10 per the CJR collection periods (90-0 days preoperative and 270-365 days postoperative) compared to an extended postoperative collection period of 270-396 days. Bivariate analysis and logistic regression were used to analyze the association between survey completion rates and patient characteristics., Results: Of the 860 primary THAs and TKAs in 2017, 725 (84.3%) had preoperative surveys completed 90-0 days before surgery. Among the 725 patients, 215 (29.7%) completed postoperative surveys within the CJR timeline of 270-365 days. Completion increased by 120 additional surveys (+16.5%) in the additional postoperative time period of 270-396 days (P < .001). No patient or procedural factors significantly correlated with a higher likelihood of postoperative PROM completion (P > .05 for all covariates)., Conclusion: In an academic clinical practice, completion rates of postoperative PROMs as part of routine clinical practice within the CJR mandated period was low for THA and TKA patients. CJR may consider additional time beyond 365 days to improve PROM completion rates., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Patient-reported outcome measures (PROMs) are important for tracking outcomes following total knee arthroplasty (TKA) but can be limited by time constraints and patient compliance. We sought to evaluate the utility of the one-question, modified single assessment numerical evaluation (M-SANE) score in TKA patients compared to legacy PROMs., Methods: Patients undergoing TKA completed the Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10), the Knee Disability and Osteoarthritis Outcomes Score Junior (KOOS Jr), and M-SANE (modified-SANE) assessments both preoperatively and postoperatively. The M-SANE score asked patients to rate their native or prosthetic knee on a scale from 0 to 10, with 10 being the best function. M-SANE validity was determined by the Spearman's correlation between the collected PROMs and the Bland-Altman plots. PROM responsiveness was assessed using the standardized response mean., Results: In total, 217 patients completed PROMs preoperatively and at 1 year postoperatively. Floor and ceiling effects of the M-SANE were higher than other PROMs but still relatively low (4%-11%). There was a moderate to strong correlation at nearly all time points between the M-SANE and KOOS Jr (ρ = 0.44-0.78, P < .001). There was a weak correlation between the M-SANE and PROMIS physical component summary at the preoperative evaluation (ρ = 0.28) but a strong correlation at 1-year follow up (0.65, P < .001). The long-term responsiveness of the M-SANE to TKA (standardized response mean [SRM] = 0.98, 95% confidence interval [CI] 0.80-1.17) was comparable to both the KOOS Jr (SRM = 1.19, 95% CI 1.00-1.38) and PROMIS physical component summary (SRM = 0.82, 95% CI 0.74-0.91). Bland-Altman plots demonstrated that the M-SANE and KOOS Jr capture combined knee pain and functionality differently., Conclusion: The M-SANE score was comparable to validated multiple-question PROMs in TKA patients. The demonstrated validity of the M-SANE, as well as its comparable responsiveness to more lengthy PROMs, highlights its use as a one-question PROM for assessment of patient undergoing TKA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: There is a lack of consensus regarding indications for surgical management of rotator cuff disease, which can lead to increased regional variation. The objectives of this study were to describe the geographic variation in rates of rotator cuff repair (RCR) in the United States over time and to identify regional characteristics associated with utilization., Methods: The United States was divided into 306 hospital referral regions. The adjusted per capita RCR rate was calculated using procedural counts derived from the Medicare Part B Carrier File from 2004-2014. Population-weighted multivariable regression was used to identify regional characteristics independently associated with utilization in 2014., Results: In 2014, an 8-fold difference in rates of RCR was found between regions. Between 2010 and 2014, the overall rate of RCR grew only 3.6% and regional variation decreased. Higher regional utilization of several other orthopedic procedures (P < .02), as well as the regional supply of orthopedic surgeons (P = .002), was independently associated with significantly increased utilization. The South, Southeast, and Southwest were independently associated with significantly higher utilization (P < .001) compared with the Northeast. A higher prevalence of resident physicians, a marker of the academic presence within a region, was independently associated with decreased utilization (P < .001)., Conclusion: Utilization of RCR has increased substantially over the past decade, but the rate of growth appears to be slowing. RCR remains a procedure with significant regional variation, and increased utilization across regions is associated with higher orthopedic surgeon supply and increased rates of other orthopedic procedures., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: Alternative payment models in total lower extremity joint replacement (TJR) increasingly emphasize patient-reported outcomes (PROs) to link the latter to value-based payments. It is unclear to what extent demographic, psychosocial, and clinical characteristics are related to PROs measured preoperatively with the commonly used Hip/Knee Osteoarthritis Outcome Scores (HOOS/KOOS) and the Veterans RAND 12-Item Health Survey (VR-12) questionnaires. We aim to identify (1) the preoperative relationship between HOOS/KOOS and VR-12 scores and several demographic, psychosocial, and clinical patient characteristics and (2) the best modifiable factors for optimization, which may result in improved baseline PROs before TJR., Methods: All TJR cases performed in 2017 at the two highest-volume hospitals within an urban academic health system were queried. Preoperative HOOS/KOOS and VR-12 surveys were administered through an e-collection platform. VR-12 physical and mental component scores (PCS, MCS) were generated. Patient information was extracted from the electronic health record. Bivariate and multivariate regression analyses were performed. Odds ratios (ORs) and 95% confidence intervals were reported., Results: In univariate analysis, patients with HOOS/KOOS, VR-12 PCS, and MCS in the ≤25th percentile group were more likely to have an ASA score of ≥3 compared with those with higher scores. In multivariate analysis, increased and decreased odds of low HOOS/KOOS were associated with a one-unit increase in Charlson Comorbidity Index (OR, 1.16) and VR-12 MCS (OR, 0.97), respectively. Increased odds of low baseline VR-12 PCS and MCS were associated with ASA class ≥3 (OR, 1.65 and 1.40). Decreased odds of a low MCS were associated with an increase in HOOS/KOOS (OR, 0.98) ( P ≤ 0.05 for all)., Conclusion: Of the factors that are associated with low baseline PRO scores, preoperatively addressing mismanaged comorbidities, mental health, and physical function were identified as the best modifiable factors for optimization, which may result in improved baseline PROs before TJR.

Payors, purchasers, health care providers, and patients are increasingly focused on improving the value-defined as health outcomes that matter to patients per dollar expended-of health care delivered to patients. Orthopaedic providers are in a unique position to pioneer this transition given the introduction of alternative payment models as well as the longitudinal, multidisciplinary, and relatively homogenous nature of high-cost, high-burden orthopaedic conditions (eg, osteoarthritis). First, doing so requires identifying and objectively measuring outcomes that are important to patients (eg, quality of life, pain, functional status) over time. Second, it requires applying value-based principles by reorganizing delivery systems into integrated practice units-a team-based, multidisciplinary model-focused on delivering longitudinal care in a method that is tailored to each patient's values, goals, and disease state. Third, providers must understand the true cost of delivering such care through time-driven activity-based costing approaches. With this knowledge of outcomes and cost, providers and payors/purchasers will be adequately equipped to develop contracts that reward providers for delivering better value (across an orthopaedic patient population) while minimizing risk. The transition to value-based health care is feasible regardless of practice setting.

Background: Anterior total hip arthroplasty (THA) allows the use of intraoperative fluoroscopy to assess leg-length and offset discrepancies. Two techniques to accomplish this are the transverse rod method and the radiographic overlay method. The aim of this study was to determine if they are equally effective options for minimizing postoperative radiologic discrepancies., Methods: We completed a retrospective cohort study comparing 106 anterior THAs from 1 surgeon using the transverse rod technique to 94 anterior THAs from another surgeon using the radiograph overlay technique. Radiographic leg-length discrepancy (LLD) and offset discrepancy (OD) were measured independently on postoperative radiographs. Parametric, nonparametric, and categorical statistical tests were used to compare LLD and OD between groups., Results: Baseline characteristics were similar between groups. The mean LLD of 4.8 mm in the radiograph overlay group was not significantly different from the 4.4 mm mean discrepancy in the transverse rod group ( P  = .424), and the rates of LLD < 5 mm and LLD < 10 mm were not significantly different ( P  = .772, P  = .179). The mean OD of 5.1 mm in the radiograph overlay group was not significantly different from the 4.8 mm mean discrepancy in the transverse rod group ( P  = .668), and there was no significant difference in the rates of OD < 5 mm and OD < 10 mm ( P  = .488, P  = .878)., Conclusions: There was no difference between the measured LLD and OD by the 2 surgeons, suggesting that the techniques are equally effective options.