90-day Reimbursements Research Articles

Anatomic and reverse total shoulder arthroplasty: variables affecting 90-day overall reimbursement

BackgroundTotal shoulder arthroplasty (TSA) is a common orthopedic procedure that can be performed as an anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA). These are effective procedures that are being performed with increasing frequency. Understanding the overall 90-day reimbursement variability and their drivers may help the health care systems better understand related considerations to reduce health-care expenditure. The current study predicts there will be large variability in reimbursement highlighting the need for further understanding. MethodsUsing the 2015-2021 Q1 M151 PearlDiver dataset, patients who underwent aTSA or rTSA were isolated. Patients were excluded if they were aged less than 18 years, had an indication of traumatic, infectious, or oncologic diagnoses within 90-days of surgery, or were not in the dataset for at least 90 days before and after surgery. Patient demographics, comorbidities, 90-day postoperative events, insurance type, and geographic region were abstracted. The overall 90-day reimbursements were then assessed and correlated with these variables having multivariable linear regression. ResultsA total of 112,188 TSA patients (aTSA: 36,164 [32.2%]; rTSA: 76,024 [67.8%]) were identified. The average ± standard deviation 90-day overall postoperative reimbursement for aTSA was $6714.26 ± 9587.46 and rTSA was $6246.45 ± 9506.59. The total reimbursement for aTSA was $242,814,515 and for rTSA was $474,836,301. Variables independently associated with greater 90-day overall reimbursement were mostly related to 90-day postoperative events, including hospital readmission [+$6694.51], emergency department visit [+$2129.89], and adverse events [+$2055.84]), geographic region of the country where the procedure was performed (relative to West, South [+$4302.88], Midwest [+$3428.84], and Northeast [+$530.92]), and insurance plan (relative to commercial, Medicare [-$1268.01], and Medicaid [-$901.79]) (P < .0001 for each). Lesser factors included male sex (relative to female +$207.30), Elixhauser-Comorbidity Index (+$51.93 per point increase), age (-$77.16 per year increase), and rTSA surgery type (relative to aTSA -$556.17). Discussion and conclusionThe current study leveraged a large, administrative database to evaluate over 100,000 TSA patients and found large variations in 90-day overall reimbursements. The variables mostly associated with increased reimbursement were related to 90-day postoperative events (as might be expected and underscoring the need to minimize such events) and geographic regions and insurance plan (highlighting differences that might be able to be addressed). Interestingly, while patient demographics, comorbidities, and anatomic vs. reverse total shoulder were associated with reimbursements, these were to lesser extents. Understanding these results may help health-care systems further target variables associated with greater cost/reimbursement to the system.

Preoperative Depression Screening for Primary Total Knee Arthroplasty: An Evaluation of Its Modifiability on Outcomes in Patients Who Have Depression

BackgroundFew studies have evaluated preoperative depression screenings in patients who have depression. We studied whether depression screenings before total knee arthroplasty (TKA) were associated with lower: 1) medical complications; 2) emergency department (ED) utilizations and readmissions; 3) implant complications; and 4) costs. MethodsA nationwide sample from January 1, 2010, to April 30, 2021, was collected using an insurance database. Depression patients were 1:1 propensity-score matched based on those who had (n = 29,009) and did not have (n = 29,009) preoperative depression screenings or psychotherapy visits within 3 months of TKA. A case-matched population who did not have depression was compared (n = 144,994). A 90-day period was used to compare complications and health-care utilization and 2-year follow-up for periprosthetic joint infections (PJIs) and implant survivorship. Costs were 90-day reimbursements. Logistic regression models computed odds ratios (ORs) of depression screening on dependent variables. P values less than .001 were significant. ResultsPatients who did not receive preoperative screening were associated with higher medical complications (18.7 versus 5.2%, OR: 4.15, P < .0001) and ED utilizations (11.5 versus 3.2%, OR: 3.93, P < .0001) than depressed patients who received screening. Patients who had screening had lower medical complications (5.2 versus 5.9%, OR: 0.88, P < .0001) and ED utilizations compared to patients who did not have depression (3.2 versus 3.8%, OR: 0.87, P = .0001). Two-year PJI incidences (3.0 versus 1.3%, OR: 2.63, P < .0001) and TKA revisions (4.3 versus 2.1%, OR: 2.46, P < .0001) were greater in depression patients who were not screened preoperatively versus screened patients. Depression patients who had screening had lower PJIs (1.3 versus 1.8%, OR: 0.74, P < .0001) compared to nondepressed patients. Reimbursements ($13,949 versus $11,982; P < .0001) were higher in depression patients who did not have screening. ConclusionsPreoperative screening was associated with improved outcomes in depression patients. Level of evidenceIII.

Total Knee Arthroplasty: Variables Affecting 90-day Overall Reimbursement

BackgroundTotal knee arthroplasty (TKA) is commonly considered to address symptomatically limiting knee osteoarthritis. With increasing utilization, understanding the variability and related drivers may help the healthcare system optimize delivery to the large numbers of patient to whom it is offered. MethodsA total of 1,066,327 TKA patients who underwent primary TKA were isolated from a 2010 to 2021 PearlDiver national dataset. Exclusion criteria included patients less than 18 years old and traumatic, infectious, or oncologic indications. Overall, 90-day reimbursements and variables associated with the patient, surgical procedure, region, and perioperative period were abstracted. Multivariable linear regressions were performed to determine independent drivers of reimbursement. ResultsThe 90-day postoperative reimbursements had an average (standard deviation) of $11,212.99 ($15,000.62), a median (interquartile range) of $4,472.00 ($13,101.00), and a total of $11,946,962,912. Variables independently associated with the greatest increase in overall 90-day reimbursement were related to admission (in-patient index-procedure [+$5,695.26] or hospital readmission [+$18,495.03]). Further drivers were region (Midwest +$8,826.21, West +$4,578.55, South +$3,709.40; relative to Northeast), insurance (commercial +$4,492.34, Medicaid +$1,187.65; relative to Medicare), postoperative emergency department visits (+$3,574.57), postoperative adverse events (+$1,309.35), (P < .0001 for each). ConclusionThe current study assessed over a million TKA patients and found large variations in reimbursement/cost. The largest increases in reimbursement were associated with admission (readmission or index procedure). This was followed by region, insurance, and other postoperative events. These results underscore the necessity to balance performing out-patient surgeries in appropriate patients versus the risk of readmissions and defined other areas for cost containment strategies.

Preoperative Depression Screening in Primary Lumbar Fusion: An Evaluation of Its Modifiability on Outcomes in Patients with Diagnosed Depressive Disorder

Studies have reported the detrimental effects of depression following spine surgery; however, none have evaluated whether preoperative depression screening in patients with a history of depression is protective from adverse outcomes and lowers health care costs. We studied whether depression screenings/psychotherapy visits within 3 months before 1- to 2-level lumbar fusion were associated with lower medical complications, emergency department utilization, readmissions, and health care costs. The PearlDiver database from 2010 to 2020 was queried for depressive disorder (DD) patients undergoing primary 1- to 2-level lumbar fusion. Two cohorts were 1:5 ratio matched and included DD patients with (n= 2,622) and DD patients without (n= 13,058) a preoperative depression screen/psychotherapy visit within 3 months of lumbar fusion. A 90-day surveillance period was used to compare outcomes. Logistic regression models computed odds ratio (OR) of complications and readmissions. P value < 0.003 was significant. DD patients without depression screening had significantly greater incidence and odds of experiencing medical complications (40.57% vs. 16.00%; OR 2.71, P < 0.0001). Rates of emergency department utilization were increased in patients without screening versus screening (15.78% vs. 4.23%; OR 4.25, P < 0.0001), despite no difference in readmissions (9.31% vs. 9.53%; OR 0.97, P= 0.721). Finally, 90-day reimbursements ($51,160 vs. $54,731) were significantly lower in the screened cohort (all P < 0.0001). Patients who underwent a preoperative depression screening within 3 months of lumbar fusion had decreased medical complications, emergency department utilization, and health care costs. Spine surgeons may use these data to counsel their patients with depression before surgical intervention.

Primary Cervical Disc Arthroplasty Among Medicare Beneficiaries Versus Alternative Payers: Is It Time to Consider Nationwide Coverage?

Retrospective cohort study. As of 2022, the Centers for Medicare and Medicaid Services does not provide nationwide coverage for cervical disc arthroplasty (CDA). The aim was to determine whether Medicare beneficiaries have differences in: (1) lengths of stay (LOS); (2) complications; (3) readmissions; and (4) costs of care. Using the 2010 to 2020 PearlDiver database, we queried patients undergoing primary CDA for degenerative disc pathology. Study groups patients were those undergoing CDA with Medicare coverage (n = 1467); patients without Medicare coverage were the comparison cohort (n = 15,389). Endpoints were to compare demographics and comorbidities within the Elixhauser comorbidity index (ECI), LOS, 90-day complications, 90-day readmissions, and 90-day reimbursements. A multivariate logistic regression was used to calculate odds (OR) of medical complications and readmissions within 90-days. A P-value less than .003 was significant. Patients with Medicare coverage undergoing CDA had higher mean ECI compared to alternative payers (5.24 vs 3.26; P < .0001). Mean LOS was significantly higher for Medicare beneficiaries (2.20 vs 1.76 days; P < .010). There was no significant differences in odds of all medical complications (OR: 1.19, 95% CI: .98-1.44; P = .069) or readmission rates (1.77% vs 1.33%, OR:0.82, 95% CI: .50-1.29; P = .417) within 90-days following the index procedure among Medicare beneficiaries vs alternative payers. Non-Medicare beneficiaries had higher 90-day reimbursements compared to Medicare beneficiaries ($6,700 vs $7,086,P < .001). Medicare beneficiaries despite having slightly longer lengths of stay did not have higher rates of medical complications or readmissions. Surgeons and policy makers may use this data to consider alternative treatments in Medicare patients.

Benign prostatic hyperplasia is associated with increased 90-day medical complications but not peri-prosthetic joint infections following reverse shoulder arthroplasty.

Studies have shown male sex to be a predisposing factor for peri-prosthetic joint infections (PJIs). Symptomatic benign prostatic hyperplasia (BPH) has been suggested as an additional risk for PJI. This study aimed to assess the impact of BPH on (1) lengths of stay (LOS), (2) complications (medical and implant-related), (3) readmission rates, and (4) healthcare expenditures after reverse shoulder arthroplasty (RSA). Utilizing a nationwide sample from the 2010-2020 PearlDiver insurance database, an analysis was performed retrospectively for all males who underwent primary RSA. Males with BPH (n = 2,184) represented the study group and were ratio-matched with men without a history of BPH (n = 10,832) in a 1:5 manner by medical comorbidities. T-tests compared LOS and healthcare expenditures. Multivariate logistic regression models were used to determine the effect of BPH on 90-day medical complications, 2-year implant complications, and readmissions. A p value less than 0.001 was statistically significant. In-hospital LOS (1.96days vs. 1.99days, p = 0.683) did not significantly differ between cohorts. Males with BPH had significantly greater occurrence and odds (34.3% vs. 21.2%, odds ratio (OR):1.84, p < 0.0001) of all 90-day medical complications, including urinary tract infections (9.3% vs. 3.1%, OR:3.23, p < 0.0001), pneumonias (6.0% vs. 3.9%, OR:1.61, p < 0.0001), and acute kidney injuries (7.7% vs. 5.0%, OR:1.60, p < 0.0001). Two-year implant-related complications were comparable between study and control groups (12.2% vs 10.9%, OR:1.14, p = 0.073), including PJIs (2.3% vs. 2.2%, OR:1.02, p = 0.874). Readmission rates (1.88% vs. 2.11%, p = 0.482) and average global 90-day reimbursements ($26,301 vs. $24,399), p = 0.535) were similar between men with and without BPH. Males with a history of BPH have greater rates of medical complications, including UTIs and acute kidney injuries, within 90days following RSA. BPH does not appear to be a risk factor for 2-year implant-related complications including PJIs. III.

Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs.

Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability. Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure. The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures. Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.

Simulated bundled payments for four common surgical approaches to treat degenerative cervical myelopathy: a consideration to break the clinical equipoise.

In degenerative cervical myelopathy (DCM) pathologies in which there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes compared with posterior approaches. In this era of value and bundled payment initiatives, the cost profiles of various surgical approaches will form an important consideration in decision-making. The objective of this study was to compare 90-day and 2-year reimbursements for ≥ 2-level (multilevel) anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior cervical laminectomy and fusion (LF), and cervical laminoplasty (LP) performed for DCM. The IBM MarketScan research database (2005-2018) was used to study beneficiaries 30-75 years old who underwent surgery using four approaches (mACDF, ACCF, LF, or LP) for DCM. Demographics, index surgery length of stay (LOS), complications, and discharge disposition were compared. Index admission (surgeon, hospital services, operating room) and postdischarge inpatient (readmission, revision surgery, inpatient rehabilitation), outpatient (imaging, emergency department, office visits, physical therapy), and medication-related payments were described. Ninety-day and 2-year bundled payment amounts were simulated for each procedure. All payments are reported as medians and interquartile ranges (IQRs; Q1-Q3) and were adjusted to 2018 US dollars. A total of 10,834 patients, with a median age of 54 years, were included. The median 90-day payment was $46,094 (IQR $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital payment was 62.4% (surgery/operating room 46.6%) and surgeon payments were 17.5% of the average 90-day bundle. There were significant differences in the index, 90-day, and 2-year reimbursements and their distribution among procedures. In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value because it is 70% less expensive on average than LF over 90 days.

Simulated Bundled Payments for 4 Common Surgical Approaches to Treat Degenerative Cervical Myelopathy: A Consideration to Break the Clinical Equipoise.

Retrospective cohort study. The aim was to compare 90-day and 2-year reimbursements for ≥2-level anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior laminectomy and fusion (LF) and laminoplasty (LP) done for degenerative cervical myelopathy (DCM). In DCM pathologies where there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes over posterior approaches. In the era of value and bundled payments initiatives, cost profile of various approaches will form an important consideration for decision making. IBM MarketScan Research Database (2005-2018) was used to study beneficiaries (30-75 y) who underwent surgery (mACDF, ACCF, LF, LP) for DCM. Index hospital stay (operating room, surgeon, hospital services) and postdischarge inpatient, outpatient and prescription medication payments have been used to simulate 90-day and 2-year bundled payment amounts, along with their distribution for each procedure. A total of 10,834 patients with median age of 54 years were included. The median 90-day payment was $46,094 (interquartile range: $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital was 62.4% (operating room: 46.6) and surgeon payments were 17.5% of the average 90-day bundle. There was significant difference in the index, 90-day and 2-year reimbursements and their distribution among procedures. In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate, and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value as it is on an average 70% less expensive than LF over 90 days.

Dually Insured Medicare/Medicaid Patients Undergoing Primary TJA Have More Comorbidities, Higher Complication Rates, and Lower Reimbursements Compared to Privately Insured Patients

BackgroundDual eligibility status (DES: qualifying for both Medicare and a Medicaid supplement) was recently proposed by the Center for Medicare and Medicaid Services as a socioeconomic qualifier for risk adjustment in primary total joint arthroplasty. However, the profile and outcomes of DES patients have never been compared to privately insured patients. MethodsA retrospective case–control study of the Mariner database within the PearlDiver server between 2010 and 2017 was performed. Patients aged 60 to 80 undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) (separately) were stratified based upon payer type: DES versus private payer. A propensity score-matched analysis with nearest neighbor pairing (1:1 ratio) was performed to compare 90-day outcomes and reimbursements. ResultsA total of 315,664 private and 3961 DES THA patients and 670,899 private and 2255 DES TKA patients were identified. DES patients were older and had a greater prevalence of comorbidities (31/36, P < .001). The THA DES matched cohort had greater transfusion rates (6.8% versus 3.9%, P < .001), higher 90-day emergency department visits (22.8% versus 16.3%, P < .001) and readmissions (16.8% versus 9.5%, P < .001), and lower reimbursements ($19,615 versus $13,036, P < .001). The TKA DES matched cohort had more cardiac events (0.4% versus 0.09%, P = .03), emergency department visits (25.2% versus 19.9%, P < .001), readmissions (14.4% versus 11.2%, P = .001), and reoperations (0.85% versus 0.35%, P = .03) ConclusionDES patients have different comorbidity profiles, and even after propensity score matching have a greater risk of complications and are reimbursed less compared to privately insured patients. In the setting of alternative payment models, these differences should be accounted for through risk adjustment.

Economic impact of orthopaedic care for non-fatal gunshot wounds: analysis of a public health crisis.

BackgroundThe purpose of this study was to perform an epidemiological evaluation and an economic analysis of 90-day costs associated with non-fatal gunshot wounds (GSWs) to the extremities, spine and pelvis requiring orthopaedic care in the United States.MethodsA retrospective epidemiological review of the Medicare national patient record database was conducted from 2005 to 2014. Incidence, fracture location and costs associated where evaluated. Those patients identified through International Classification of Disease (ICD)-9 revision codes and Current Procedural Terminology (CPT) Codes who sustained a fracture secondary to a GSW. Any type of surgical intervention including incision and drainage, open reduction with internal fixation, closed reduction and percutaneous fixation, etc. were identified to analyze, and evaluate costs of care as seen by charges and reimbursements to the payer. The 90-day period after initial fracture care was queried.ResultsA total of 9,765 patients required surgical orthopaedic care for GSWs. There was a total of 2,183 fractures due to GSW treated operatively in 2,201 patients. Of these, 22% were femur fractures, 18.3% were hand/wrist fractures and 16.7% were ankle/foot fractures. A majority of patients were male (83.3%) and under 65 years of age (56.3%). Total charges for GSW requiring orthopedic care were $513,334,743 during the 10-year study period. Total reimbursement for these patients were $124,723,068. Average charges per patient were highest for fracture management of the spine $431,021.33, followed by the pelvis $392,658.45 and later by tibia/fibula fractures $342,316.92.ConclusionsThe 90-day direct charges and reimbursements of orthopedic care for non-fatal GSWs are of significant amounts per patient. While the number of fatal GSWs has received much attention, non-fatal GSWs have a large economic and societal impact that warrants further research and consideration by the public and policy makers.

Compensated Cirrhosis Is Associated With Increased Risk of Complications Following Total Hip Arthroplasty in a Large Medicare Database

BackgroundThe aim of this study is to evaluate medical and surgical complications of liver cirrhosis patients following total hip arthroplasty (THA), with attention to different etiologies of cirrhosis and their financial burden following THA. MethodsIn total, 18,321 cirrhotics and 722,757 non-cirrhotics who underwent primary elective THA between 2006 and 2013 were identified from a retrospective database review. This cohort was further subdivided into 2 major etiologies of cirrhosis (viral and alcoholic cirrhosis) and other cirrhotic etiology. Cirrhotics were compared to non-cirrhotics for hospital length of stay, 90-day mean total charges and reimbursement, hospital readmission, and major medical and arthroplasty-specific complications. ResultsCirrhosis was associated with increased rates of major medical complications (4.3% vs 2.4%; odds ratio [OR] 1.20, P < .001), minor medical complications, transfusion (3.4% vs 2.1%; OR 1.16, P = .001), encephalopathy, disseminated intravascular coagulation, and readmission (13.5% vs 8.6%; OR 1.18, P < .001) within 90 days. Cirrhosis was associated with increased rates of revision, periprosthetic joint infection, hardware failure, and dislocation within 1 year postoperatively (3.1% vs 1.6%; OR 1.37, P < .001). Cirrhosis independently increased hospital length of stay by 0.14 days (P < .001), and it independently increased 90-day charges and reimbursements by $13,791 (P < .001) and $1707 (P < .001), respectively. Viral and alcoholic cirrhotics had higher rates of 90-day and 1-year complications compared to controls—other causes only had higher rates of 90-day medical complications, encephalopathy, readmission, and 1-year revision, hardware failure, and dislocation compared to controls. ConclusionCirrhosis, especially viral and alcoholic etiologies, is associated with higher risk of early postoperative complications and healthcare utilization following elective THA.

Certificate-of-Need State Laws and Elective Posterior Lumbar Fusions: Is It Time to Repeal the Mandate?

Our study aimed to assess whether elective posterior lumbar fusions (PLFs) performed in states with Certificate-of-Need (CON) laws versus states without CON laws had lower utilization rates, lower costs, and better quality of care. The 2005-2014 100% Medicare Standard Analytical File was queried to identify patients undergoing elective 1- to 3-level PLF. Differences in per-capita utilization, 90-day reimbursements, and proportion of high-volume between CON and No-CON states were reported. Multivariate analyses were used to analyze 90-day complications and readmissions. A total of 188,687 patients underwent an elective 1- to 3-level PLF in a CON state and 167,642 patients in a No-CON state during 2005-2014. The average per capita utilization of PLFs was lower in CON states as compared with No-CON states (14.5 vs. 15.4 per 10,000 population; P < 0.001). Average 90-day reimbursements between CON and No-CON states differed by a small amount ($22,115 vs. $21,802). CON states had a higher proportion of high-volume facilities (CON vs. No CON-40.9% vs. 29.9%; P < 0.05) and lower proportion of low-volume facilities (CON vs. No-CON-37.2% vs. 45.0%; P < 0.05). PLFs performed in CON states had slightly lower odds of 90-day complications (odds ratio 0.97 [95% confidence interval 0.96-0.99]; P < 0.001) and readmissions (odds ratio 0.95 [95% confidence interval 0.93-0.97]; P < 0.001). The presence of CON laws was associated with lower utilization of elective 1- to 3-level PLFs and a greater number of high-volume facilities. However, their effect on quality of care, via reduction of 90-day readmissions and 90-day complications, is minimally significant.

P110. Hospital network participation and outcomes following elective posterior lumbar fusions: are mergers warranted?

BACKGROUND CONTEXT Due to financial pressures associated with health care reforms, an increasing number of hospitals are now integrating/merging into networks or systems. However, it remains unclear as to how these mergers or network participations impact quality of care and/or costs. PURPOSE The current study aims to evaluate the impact of hospital network participation on 90-day complications, charges and costs following elective posterior lumbar fusions (PLFs). STUDY DESIGN/SETTING Retrospective review of a 100% national sample of Medicare claims from 2010-2014 (SAF100). PATIENT SAMPLE The 2010-2014 100% Medicare Standard Analytical Files (SAF100) was used to identify patients undergoing elective 1-to-3 level posterior lumbar fusions for degenerative lumbar pathology. The Dartmouth Atlas for Healthcare hospital-level data, which uses a combination of American Hospital Association and additional source data, was used to identify hospitals that were part of a network/system between 2010 and 2014. The study sample was divided into two cohorts (Network Hospitals and Non-Network Hospitals) for analyses. OUTCOME MEASURES Ninety-day complications, charges and costs. METHODS Multi-variate logistic regression models were used to compare differences in 90-day complications between network and non-network hospitals, while controlling for baseline demographics (age, gender, region, year of surgery, median household income, co-morbidity burden) and hospital-level characteristics (case volume, teaching status, urban/rural location and hospital ownership). Generalized linear regression modeling was used to assess for differences in 90-day charges and costs. RESULTS A total of 145,141 patients undergoing surgery in 2,186 hospitals were included in the study – out of which 107,919 (74.4%) underwent surgery in a network hospital (N=1,526). Network hospitals were likely to cater to patients from the South or West, and those having a median household income less than the 5th quintile. Network hospitals were also more likely to have a higher annual case volume of elective 1-to-3 PLFs, greater number of beds, be located in an urban location, and have a voluntary/non-profit or proprietary/profit ownership model. Multi-variate analyses showed that even though patients undergoing surgery at network hospitals (vs non-network hospitals) had a slightly increased odds of 90-day cardiac complications (7.9% vs 7.4%, OR 1.07 [95% CI 1.02-1.12]; p=0.010), thromboembolic complications (2.4% vs 2.2%, OR 1.12 [95% CI 1.01-1.20]; p=0.025) and emergency department visits (16.4% vs 16.0%, OR 1.06 [95% CI 1.02-1.09]; p=0.002), the differences were not clinically important/significant. Despite a slight, but clinically insignificant, decrease in risk-adjusted 90-day reimbursements (-$272), the risk-adjusted 90-day charges were actually significantly higher (+ $9,959; p CONCLUSIONS Even though hospitals that are part of a network/system do not appear to have significantly different complication rates following elective PLFs, they do have significantly higher risk-adjusted charges, as compared to non-network hospitals. Further research is required to understand market-level changes induced by hospital mergers into networks. Additionally, as the federal government increasingly pushes hospitals towards implementing value, a broader understanding of hospital network participation on outcomes following other orthopedic surgical procedures is required to best ensure that policies laid down in the upcoming years are geared towards ensuring quality health care is made equitable and accessible to all. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Hospital network participation and outcomes following elective posterior lumbar fusions – are mergers effective?

Background contextDue to financial pressures associated with healthcare reforms, an increasing number of hospitals are now merging (or consolidating) into networks (or systems). However, it remains unclear how these mergers or network participations affect quality of care and/or costs. PurposeThe current study aims to evaluate the impact of hospital network participation on 90-day complications, charges, and costs following elective posterior lumbar fusions (PLFs). Study designRetrospective review of a 100% national sample of Medicare claims from 2010 to 2014 (SAF100). Study sampleAll Medicare-eligible patients undergoing elective 1-to-3 level PLFs for degenerative lumbar pathology from 2010 to 2014. Outcome measuresNinety-day complications, charges, and costs. MethodsThe 2010 to 2014 100% Medicare Standard Analytical Files (SAF100) was used to identify patients undergoing elective 1- to 3-level PLFs for degenerative lumbar pathology. The Dartmouth Atlas for Healthcare hospital-level data, which uses a combination of American Hospital Association and additional source data, was used to identify hospitals that were part of a network (or system) between 2010 and 2014. The study sample was divided into 2 cohorts (network hospitals and non-network hospitals) for analyses. Multivariate logistic regression models were used to compare differences in 90-day complications between network and non-network hospitals, while controlling for baseline demographics (age, gender, region, year of surgery, median household income, co-morbidity burden) and hospital-level characteristics (case volume, teaching status, urban/rural location, and hospital ownership). Generalized linear regression modeling was used to assess for differences in 90-day charges and costs. ResultsA total of 145,141 patients undergoing surgery in 2,186 hospitals were included in the study, out of which 107,919 (74.4%) underwent surgery in a network hospital (N=1,526). Network hospitals were more prevalent in the South or West regions of the United States. Patients in network hospitals had a median household income less than the 5th quintile. Network hospitals were also more likely to have a higher annual case volume of elective 1- to 3-level PLFs, greater number of beds, be located in an urban location, and have a voluntary/nonprofit or proprietary/profit ownership model. Multivariate analyses showed that even though patients undergoing surgery at network hospitals (vs non-network hospitals) had a slightly increased odds of 90-day cardiac complications (7.9% vs 7.4%, odds ratio [OR] 1.07 [95% confidence interval {CI} 1.02–1.12]; p=.010), thromboembolic complications (2.4% vs 2.2%, OR 1.12 [95% CI 1.01–1.20]; p=.025) and emergency department visits (16.4% vs 16.0%, OR 1.06 [95% CI 1.02–1.09]; p=.002), the differences would not be considered clinically significant. Despite a slight decrease in risk-adjusted 90-day reimbursements (−$272), the risk-adjusted 90-day charges were actually significantly higher (+$9,959; p<.001) at network hospitals. ConclusionsEven though hospitals that are part of a network do not appear to have significantly different complication rates following elective PLFs, they do have significantly higher risk-adjusted charges as compared to non-network hospitals. Further research is required to understand market-level changes induced by hospital mergers into networks.

Current diagnosis-related group–based bundling for upper-extremity arthroplasty: a case of insufficient risk adjustment and misaligned incentives

The current Centers for Medicare & Medicaid Servicesdiagnosis-related group (DRG) bundled-payment model for upper-extremity arthroplasty does not differentiate between the type of arthroplasty (anatomic total shoulder arthroplasty [ATSA] vs. reverse total shoulder arthroplastyvs. total elbow arthroplasty [TEA] vs. total wrist arthroplasty) or the diagnosis and indication for surgery (fracture vs. degenerative osteoarthritis vs. inflammatory arthritis). The 2011-2014 Medicare 5% Standard Analytical Files (SAF5) database was queried to identify patients undergoing upper-extremity arthroplasty under DRG-483 and -484. Multivariate linear regression modeling was used to assess the marginal cost impact of patient-, procedure-, diagnosis-, and state-level factors on 90-day reimbursements. Of 6101 patients undergoing upper-extremity arthroplasty, 3851 (63.1%) fell under DRG-484 and 2250 (36.9%) were classified under DRG-483. The 90-day risk-adjusted cost of an ATSA for degenerative osteoarthritis was $14,704 ± $655. Patient-level factors associated with higher 90-day reimbursements were male sex (+$777), age 75-79 years (+$740), age 80-84 years (+$1140), and age 85 years or older (+$984). Undergoing a TEA (+$2175) was associated with higher reimbursements, whereas undergoing a shoulder hemiarthroplasty(-$1000) was associated with lower reimbursements. Surgery for a fracture (+$2354) had higher 90-day reimbursements. Malnutrition (+$10,673), alcohol use or dependence (+$6273), Parkinson disease (+$4892), cerebrovascular accident or stroke (+$4637), and hyper-coagulopathy (+$4463) had the highest reimbursements. In general, states in the South and Midwest had lower 90-day reimbursements associated with upper-extremity arthroplasty. Under the DRG-based model piloted by the Centers for Medicare & Medicaid Services, providers and hospitals would be reimbursed the same amount regardless of the type of surgery (ATSA vs. hemiarthroplasty vs. TEA), patient comorbidity burden, and diagnosis and indication for surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Lack of risk adjustment for fracture indications leads to strong financial disincentives within this model.

The Cost of Malnutrition in Total Joint Arthroplasty

BackgroundMalnutrition is a known risk factor for complications and adverse outcomes after elective total joint arthroplasty (TJA), but little is known about the burden this risk factor places on the healthcare system. The purpose of this study was to evaluate the 90-day impact of malnutrition on medical and surgical complications and understand the increase in global reimbursements associated with TJA in malnourished patients. MethodsWe queried a combined private-payer and Medicare database from 2007 to 2016 for TJA using International Classification of Diseases, 9th revision and Current Procedural Terminology codes. Patients with serum albumin level of <3.5 g/dL were gender, age, and mean Elixhauser Comorbidity Index matched against a cohort with a normal serum albumin level. Odds ratios and confidence intervals were calculated for complications at 90 days postoperatively. Mean index and 90-day global reimbursements were calculated for the two matched groups and compared using P-values. Results3053 protein malnourished patients receiving TJA were identified, and 12,202 matched protein nourished patients receiving TJA served as controls. At 90 days, the malnourished groups had increased risk for failure of multiple organ systems, periprosthetic joint infection, and reoperation. The mean 90-day increase in reimbursement was $3875 associated with performing a TJA on a protein malnourished patient (P < .001). ConclusionThis study demonstrates an association between malnourished patients and postoperative complications as well as significantly increased reimbursements. Understanding the reimbursement increases at 90 days for TJA in protein malnourished patients is important in the era of bundled payments.

Total Knee Arthroplasty among Medicare Beneficiaries with Hemophilia A and B Is Associated with Increased Complications and Higher Costs.

Operations on patients with hemophilia A and B are complex. Studies evaluating postoperative outcomes and costs following total knee arthroplasty (TKA) in patients with hemophilia are limited. A retrospective review of the entire Medicare dataset from 2005 to 2014 was performed. International Classification of Disease 9th revision codes were used to identify patients with hemophilia A and B and they were matched to controls using a 1:1 random matching process based on age, gender, Charlson Comorbidity Index (CCI), and select comorbidity burden. The 90-day preoperative period was evaluated for comorbidities and the 90-day postoperative period was analyzed for outcomes and reimbursements. Logistic regression models were generated to compare outcomes between cases and controls. A total of 4,034 patients with hemophilia were identified as having undergone TKA. About 44.8% were between the ages of 65 and 74 and 62.4% were female. Although the CCI was identical in both cohorts, individual comorbidities not controlled for varied significantly. Medical complications were more frequent among the patients with hemophilia: postoperative bleeding (odds ratio [OR]: 1.7; 95% confidence interval [CI]: 1.2-2.3), deep venous thrombosis (OR: 2.3; 95% CI: 1.8-2.8), pulmonary embolism (OR: 2.9; 95% CI: 2.1-3.9), and blood transfusions (OR: 1.8; 95% CI: 1.6-1.9). Hemophilia was associated with higher odds of periprosthetic infection (1.78 vs. 0.98%, OR: 1.8 95% CI: 1.2-2.7). The 90-day reimbursements were higher for patients with hemophilia (mean: $22,249 vs. $13,017, p < 0.001). Medicare beneficiaries with a diagnosis of hemophilia experience more frequent postoperative complications and incur greater 90-day costs than matched controls following TKA. Surgeons should consider this when optimizing patients for TKA and payors should consider this for risk-adjusting payment models.

93. Certificate-of-Need state laws and elective posterior lumbar fusions: a Medicare trends, costs and outcomes analysis

BACKGROUND CONTEXT Certificate-of-Need (CON) state laws have been a major mandate of health policies aimed at forming centralized health planning as a key-core of the US health care system. Though the federal CON mandate was repealed in 1986, several states still continue to use it as a means of limiting health care resource utilization while attempting to provide quality care in high-volume facilities. PURPOSE The current study aimed to utilized a national Medicare claims dataset to assess whether elective posterior lumbar fusions (PLFs) performed in CON vs No CON states had lower utilization rates, lower costs, and better quality of care. STUDY DESIGN/SETTING Retrospective review of administrative claims from the 100% Medicare Standard Analytical Files (SAF100). PATIENT SAMPLE The 2005-2014 100% Medicare Standard Analytical File (SAF100) was queried to identify patients undergoing elective 1-to-3 level PLF. OUTCOME MEASURES Trends in utilization during the study period (2005-2014), average 90-day costs/reimbursements, 90-day complications and 90-day readmissions. METHODS Patients were categorized into ‘CON’ and ‘No CON’ based on existing state laws where they received the procedure. For each group (CON vs No CON), differences in per-capita utilization, 90-day reimbursements and proportion of high-volume facilities (>150 procedures/year) vs low-volume facilities (≤50 procedures/year) have been reported. Multivariate analyses were used analyze 90-day complication/readmission rates between the two groups. RESULTS A total of 188,687 patients underwent an elective 1- to 3-level PLF in a CON state and 167,642 patients received the procedure in a No CON state from 2005 to 2014. The average per capita utilization of PLFs was lower in CON states as compared to No CON states (14.5 vs 15.4 per 10,000 population; p CONCLUSIONS While the presence of CON laws was associated with lower utilization of elective 1-to-3 level PLFs, and a greater presence of high-volume facilities, the mandate's effect on enhancing quality-of-care, by reduction of 90-day readmissions and 90-day complications is minimally significant. Future research, involving other surgical subspecialties, is needed before health policy makers may consider the removal or alteration of these laws. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Complications and Costs Are Not Increased After Total Hip Arthroplasty in Patients With a History of Prostate Cancer

BackgroundProstate cancer (PCa) is a largely prevalent disease in the United States. Moreover, it is unclear whether the thromboembolic burden of disease remains present after the cancer has been treated and whether such state impacts the short-term outcomes of orthopedic procedures. Therefore, the purpose of this study is to assess 90-day postoperative complications and costs after total hip arthroplasty (THA) for osteoarthritis in patients with a history of PCa. MethodsTwo groups of patients who underwent THA for osteoarthritis in the Medicare Standard Analytical Files were identified through the PearlDiver server. Both groups were matched based on age, diabetes, smoking status, chronic kidney disease, alcohol abuse, chronic liver disease, and obesity in order to create a case-control study comparison. The 90-day complication rates after THA were compared using univariate regressions (odds ratio). We hypothesized that patients with a history of PCa would develop increased rates of thromboembolic complications based on a prolonged procoagulative state. ResultsAfter matching, each group was comprised of 62,571 patients. Our findings identified greater 90-day pneumonia rates for those without a history of PCa (3.26% vs 2.68%; odds ratio, 0.82). All other complications including thromboembolic diseases were clinically comparable in both groups during the 90-day postoperative period. The charges and reimbursements for the 90-day period were also comparable. ConclusionIn our large case-control study of 125,142 patients, we found that patients with a history of PCa do not have increased risk of short-term complications after THA and that the mean 90-day reimbursements were similar for both groups at $14,153 for PCa patients and $14,033 for those without (P = .114).