Comprehensive Joint Replacement Research Articles

Social risk and patient-reported outcomes after total knee replacement: Implications for Medicare policy.

To determine whether county-level or patient-level social risk factors are associated with patient-reported outcomes after total knee replacement when added to the comprehensive joint replacement risk-adjustment model. Patient and outcomes data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement cohort were merged with the Social Vulnerability Index from the Centers for Disease Control and Prevention. This prospective longitudinal cohort measured the change in patient-reported pain and physical function from baseline to 12 months after surgery. The cohort included a nationally diverse sample of adult patients who received elective unilateral knee replacement between 2012 and 2015. Using a national network of over 230 surgeons in 28 states, the cohort study enrolled patients from diverse settings and collected one-year outcomes after the surgery. Patients <65 years of age or who did not report outcomes were excluded. After adjusting for clinical and demographic factors, we found patient-reported race, education, and income were associated with patient-reported pain or functional scores. Pain improvement was negatively associated with Black race (CI = -8.71, -3.02) and positively associated with higher annual incomes (≥$45,00) (CI = 0.07, 2.33). Functional improvement was also negatively associated with Black race (CI = -5.81, -0.35). Patients with higher educational attainment (CI = -2.35, -0.06) reported significantly less functional improvement while patients in households with three adults reported greater improvement (CI = 0.11, 4.57). We did not observe any associations between county-level social vulnerability and change in pain or function. We found patient-level social factors were associated with patient-reported outcomes after total knee replacement, but county-level social vulnerability was not. Our findings suggest patient-level social factors warrant further investigation to promote health equity in patient-reported outcomes after total knee replacement.

The Role of Physician Integration in Alternative Payment Models: The Case of the Comprehensive Joint Replacement Program

The Role of Physician Integration in Alternative Payment Models: The Case of the Comprehensive Joint Replacement Program

Economic Impact of Outpatient Medicare Total Knee Arthroplasty at a Tertiary Care Academic Medical Center

BackgroundIn January 2018, the Center for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the inpatient-only list. This impacted hospital reimbursement, Comprehensive Joint Replacement (CJR) bundle volumes, and bundle performance. We describe these impacts at an academic teaching hospital. MethodsWe reviewed CJR bundle data provided by CMS and internal databases to identify the shift in CJR TKA episode volume since January 2018, the impact on postacute care (PAC) utilization rates and readmissions, financial impact to the bundle, and impact on hospital reimbursement. We used data provided to CJR participants, internal hospital sources, and the Medicare Limited Data Set. ResultsBetween 2017 and 2018, CJR TKA episodes decreased from 91 to 51 (44% reduction). Inpatient PAC utilization was significantly higher in 2018 (20% vs 8%). The 90-day readmission rates increased from 5.5% to 12.7%. Average variance to target dropped from 15% to 5%. Average CMS reimbursement for TKA at our institution in 2019 was $14,823 for inpatients and $9299 for outpatients. We experienced $930,463 in decreased reimbursement from January 2018 to September 2019 as a result of the shift from inpatient to outpatient. In addition, we expect $625,143 in decreased incentive payments as higher functioning and lower cost outpatient TKAs are excluded from CJR. ConclusionAlthough CMS projected a minimal impact on CJR bundle participants, this has not been the case at our institution. We experienced reduced volumes, increased PAC utilization, and a substantial financial impact. We expect a similar outcome when CMS removes total hip arthroplasty from the inpatient-only list.

Developing and Implementing a Digital Navigation Program to Improve Outcomes for Medicare Bundle Patients Undergoing Joint Replacement Surgery

Background Evidence-based patient education and consistent, timely communication is key to ensuring good outcomes among joint replacement patients. Mount Sinai Hospital (MSH) participates in the mandatory CMS bundle for comprehensive joint replacement (CJR). MSH’s bundled payment strategy focuses on the development of a standardized model of care, built around evidence-based best practices to achieve the triple aims of strengthening population health while controlling cost and improving the quality of care. MSH launched a comprehensive digital navigation program (DNP) to guide joint replacement patients and their caregivers through pre-surgical preparation and recovery. Objective The objective was to improve the quality of care for joint replacement patients through creation of a digital navigation program specifically tailored to Medicare patients (age 65+) across the continuum of care. Methods Mount Sinai App Lab, in collaboration with the Department of Orthopedics, developed three digital therapeutic modules that were delivered through the RxUniverse Digital Medicine platform (Rx.Health, NY). These automated messages, programmed to send at specific times, included exercise instructions, medication reminders, and suggestions for how to prepare the home for optimal recovery. Messages specifically targeted key patient outcomes: length of stay, readmissions, ambulation on postoperative day 0, and discharge disposition. Staff “prescribed” each module to patients to ensure that engagement aligned with their process of care. Results Clinicians, patients, and their caregivers were receptive to the DNP. Patients showed a high rate of engagement, clicking links to educational content 873 times, and patients called their case manager or surgeon’s office to clarify their next steps when prompted. After 9 months, clinical outcomes for the digital navigation program were compared to other Medicare patients who had not received it. DNP patients had significantly shorter length of stay than their peers (2.81 vs 4.31 days). They also had a lower readmission rate (1.9% vs 2.9%) as well as a higher rate of discharge to home (87.8% vs 64.3%) and were more likely to ambulate on the day of surgery (47.9% vs 33.3%). Twenty patients responded to an end-of-program survey about their experience; 18 patients (90%) agreed that the program was helpful with the process of their total joint replacement surgery, 2 patients neither agreed nor disagreed (10%), and 0 patients disagreed. When asked about their satisfaction with the message volume, 19 patients answered “yes, this was the perfect number,” (95%) and 1 patient answered “no, I want fewer messages” (5%). Patient qualitative feedback was very positive. Patients reported, “Texts reassured me and helped me along with my progress and recovery,” and “Good support. Thank you.” A third said, “The texting program serves as a great reminder as what to do and when.” Conclusions The CJR DNP provided a direct, automated channel to educate and support patients at each stage of care. It demonstrated that digital navigation technology can be used even among non-digital native populations. It resulted in a significantly reduced length of stay and hospital readmissions among participating patients. Next steps include scaling the program across the health system and adding Spanish-language support. Similar programs are now being implemented for other surgical and disease use cases.

Considerations for Office and Staff Protocols for Outpatient Joint Replacement

Elements of a successful comprehensive joint replacement program include preoperative education, joint class or camps, office support, and follow-up staff and systems. To meet the demand for consistent and safe outpatient joint replacement discharges, these elements must be optimized and, in many cases, enhanced beyond standard procedures. The office and staff protocols that support the outpatient joint replacement patient before and after surgery are as important as the surgery itself. There are unique consequences, or “ripple effects”, of speeding patient recovery after joint replacement surgery and proceeding to early discharges. By understanding these differences and by being proactive, rather than reactive, the enhanced protocols can provide a safe and successful outpatient experience.

The Distinct Value of Occupational Therapy: Relationship Between Self-Care and Outcomes in the Comprehensive Joint Replacement Payment Model

Abstract Date Presented 4/19/2018 Occupational therapy enables a full life by enhancing function. The unique value of occupational therapy as demonstrated by relationships between self-care and outcomes in a comprehensive joint replacement payment model is discussed. Data presented support this value and provide discussion to optimize occupational therapy intervention practices. Primary Author and Speaker: Angela Edney Additional Authors and Speakers: Susan Almon-Matangos, Donna Diedrich, Lynn Freeman

Predicting the Incremental Hospital Cost of Adverse Events Among Medicare Beneficiaries in the Comprehensive Joint Replacement Program During Fiscal Year 2014

BackgroundThe Medicare program's Comprehensive Care for Joint Replacement (CJR) payment model places hospitals at financial risk for the treatment cost of Medicare beneficiaries (MBs) undergoing lower extremity joint replacement (LEJR). MethodsThis study uses Medicare Provider Analysis and Review File and identified 674,777 MBs with LEJR procedure during fiscal year 2014. Adverse events (death, acute myocardial infarction, pneumonia, sepsis or shock, surgical site bleeding, pulmonary embolism, mechanical complications, and periprosthetic joint infection) were studied. Multivariable regressions were modeled to estimate the incremental hospital cost of treating each adverse event. ResultsThe risk-adjusted estimated hospital cost of treating adverse events varied from a high of $29,061 (MBs experiencing hip fracture and joint infection) to a low of $6308 (MBs without hip fracture that experienced pulmonary embolism). ConclusionAvoidance of adverse events in the LEJR hospitalization will play an important role in managing episode hospital costs in the Comprehensive Care for Joint Replacement program.

Preparing the Next Generation of Physical Therapists for Transformative Practice and Population Management: Example From Macquarie University.

The new and major challenge to health care is the advent of chronic diseases. The successes of treating people with infectious diseases, the wave of the aging population, changing lifestyles, obesity, and physical inactivity have contributed to a public health epidemic of chronic diseases (ie, diabetes, stroke, Alzheimer disease, arthritis, and heart failure). Because of its personal, social, and economic impact, tackling chronic disease is the new frontier of modern medicine. Management of chronic diseases will not be solved by “magic bullets,” a surgical intervention, or the “heroics of medical rescue.” Chronic disease management requires holistic, patient-centered care, with collaborating and respectful teams of interdisciplinary providers (physicians, nurses, pharmacists, and allied health workers). These teams will coordinate care across the continuum. In addition, our current medical and public health initiatives must be prepared to address not only the medical conditions but also the social determinants of health. Atul Gawande, a surgeon and health care thought leader, wrote that health care “now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person's abilities [our emphasis].”1(p183) Individual professional and personal autonomy is not the ideal we should seek. The next generation of solutions will require new skills among physical therapists to be partners in the treatment of populations of patients across the continuum of health care settings and coach patients and families in lifestyle management and be accountable for sustaining and improving functional status. The Centers for Medicare & Medicaid Services recently implemented bundled payments for hip and knee replacements in 67 geographic areas in the United States.2 Under this comprehensive joint replacement model, the hospital that performs the surgery will be accountable for the costs and quality of related care for the episode of care, which is from the time of the surgery through …

Commentary on the Comparative Effectiveness of Alternative Settings for Joint Replacement Rehabilitation

Stineman MG, Chan L. Commentary on the comparative effectiveness of alternative settings for joint replacement rehabilitation. The comprehensive Joint Replacement Outcomes in Inpatient Rehabilitation Facilities and Nursing Treatment Sites 1 and 2 studies presented in this issue of the Archives by DeJong and colleagues focus on an important issue facing U.S. rehabilitation today: the comparative effectiveness of alternative rehabilitation settings for the management of conditions such as joint replacement. Although there are hints in the data that patients receiving care in inpatient rehabilitation facilities compared with those treated in skilled nursing facilities may have slightly better recoveries of physical function, the evidence is weaker than for a number of other conditions. It is important to look beyond the question of which setting is best, toward gaining a deeper understanding of the elements within these settings that most enhance outcomes.

A comprehensive joint replacement program for total knee arthroplasty: a descriptive study

BackgroundTotal knee arthroplasty (TKA) is a commonly performed surgical procedure in the US. It is important to have a comprehensive inpatient TKA program which maximizes outcomes while minimizing adverse events. The purpose of this study was to describe a TKA program – the Joint Replacement Program (JRP) – and report post-surgical outcomes.Methods74 candidates for a primary TKA were enrolled in the JRP. The JRP was designed to minimize complications and optimize patient-centered outcomes using a team approach including the patient, patient's family, and a multidisciplinary team of health professionals. The JRP consisted of a pre-operative class, standard pathways for medical care, comprehensive peri-operative pain management, aggressive physical therapy (PT), and proactive discharge planning. Measures included functional tests, knee range of motion (ROM), and medical record abstraction of patient demographics, length of stay, discharge disposition, and complications over a 6-month follow-up period.ResultsAll patients achieved medical criteria for hospital discharge. The patients achieved the knee flexion ROM goal of 90° (91.7 ± 5.4°), but did not achieve the knee extension ROM goal of 0° (2.4 ± 2.6°). The length of hospital stay was two days for 53% of the patients, with 39% and 7% discharged in three and four days, respectively. All but three patients were discharged home with functional independence. 68% of these received outpatient physical therapy compared with 32% who received home physical therapy immediately after discharge. Two patients (< 3%) had medical complications during the inpatient hospital stay, and 9 patients (12%) had complications during the 6-month follow-up period.ConclusionThe comprehensive JRP for TKA was associated with satisfactory clinical outcomes, short lengths of stay, a high percentage of patients discharged home with outpatient PT, and minimal complications. This JRP may represent an efficient, effective and safe protocol for providing care after a TKA.