Search

Background: Musculoskeletal providers are increasingly recognizing the importance of social factors and their association with health outcomes as they aim to develop more comprehensive models of care delivery. Such factors may account for some of the unexplained variation between pathophysiology and level of pain intensity and incapability experienced by people with common conditions, such as persistent nontraumatic knee pain secondary to osteoarthritis (OA). Although the association of one's social position (for example, income, employment, or education) with levels of pain and capability are often assessed in OA research, the relationship between aspects of social context (or unmet social needs) and such symptomatic and functional outcomes in persistent knee pain are less clear. Questions/purposes: (1) Are unmet social needs associated with the level of capability in patients experiencing persistently painful nontraumatic knee conditions, accounting for sociodemographic factors? (2) Do unmet health-related social needs correlate with self-reported quality of life? Methods: We performed a prospective, cross-sectional study between January 2021 and August 2021 at a university academic medical center providing comprehensive care for patients with persistent lower extremity joint pain secondary to nontraumatic conditions such as age-related knee OA. A final 125 patients were included (mean age 62 ± 10 years, 65% [81 of 125] women, 47% [59 of 125] identifying as White race, 36% [45 of 125] as Hispanic or Latino, and 48% [60 of 125] with safety-net insurance or Medicaid). We measured patient-reported outcomes of knee capability (Knee injury and Osteoarthritis Outcome Score for Joint Replacement), quality of life (Patient-Reported Outcome Measure Information System [PROMIS] Global Physical Health and PROMIS Global Mental Health), and unmet social needs (Accountable Health Communities Health-Related Social Needs Survey, accounting for insufficiencies related to housing, food, transportation, utilities, and interpersonal violence), as well as demographic factors. Results: After controlling for demographic factors such as insurance status, education attained, and household income, we found that reduced knee-specific capability was moderately associated with experiencing unmet social needs (including food insecurity, housing instability, transportation needs, utility needs, or interpersonal safety) (standardized beta regression coefficient [β] = -4.8 [95% confidence interval -7.9 to -1.7]; p = 0.002 and substantially associated with unemployment (β = -13 [95% CI -23 to -3.8]; p = 0.006); better knee-specific capability was substantially associated with having Medicare insurance (β = 12 [95% CI 0.78 to 23]; p = 0.04). After accounting for factors such as insurance status, education attained, and household income, we found that older age was associated with better general mental health (β = 0.20 [95% CI 0.0031 to 0.39]; p = 0.047) and with better physical health (β = 0.004 [95% CI 0.0001 to 0.008]; p = 0.04), but effect sizes were small to negligible, respectively. Conclusion: There is an association of unmet social needs with level of capability and unemployment in patients with persistent nontraumatic knee pain. This finding signals a need for comprehensive care delivery for patients with persistent knee pain that screens for and responds to potentially modifiable social risk factors, including those based on one's social circumstances and context, to achieve better outcomes. Level of Evidence: Level II, prognostic study. [ABSTRACT FROM AUTHOR]

Abstract: Health-care expenses have been projected to increase from 17.7% of the U.S. gross domestic product (GDP) in 2014 to 19.6% in 2024. The unsustainable increase in health-care costs has contributed toward support for value-based health care (VBHC) reform. Contemporary VBHC reform programs relevant to orthopaedic surgery include the voluntary Bundled Payments for Care Improvement initiatives (BPCI and BPCI-Advanced) and the Comprehensive Care for Joint Replacement (CJR) program, a mandatory bundled payment program.The purported benefits of transitioning from volume-based reimbursement to value-based reimbursement include moving from a fragmented provider-centered care model to a patient-centered model, with greater care coordination and alignment among providers focused on improving value. VBHC models allow innovative strategies to proactively invest resources to promote value (e.g., the use of nurse navigators) while eliminating unnecessary resources that do not promote value. However, major concerns regarding VBHC include the absence of medical and socioeconomic risk stratification as well as decreased access for higher-risk patients.This article identifies the benefits and potential unintended consequences of VBHC reform, with a focus on joint arthroplasty. We also discuss some potential strategies to promote innovation and improve value without compromising access for vulnerable patients. [ABSTRACT FROM AUTHOR]

One factor that can make the transition to value-based payment models easier is that many current APMs are based on a fee-for-service architecture and can be more readily adopted by orthopaedic practices that are newer to value-based healthcare [[4]]. Although most stakeholders agree that focusing on value is one of the keys to an effective and sustainable healthcare system [[11]], a large contingent of healthcare providers, including orthopaedic surgeons, are concerned that implementing value-based healthcare strategies within their health system or practice may have unintended consequences. Together, shared decision-making, PRO measurement, and multidisciplinary team-based care can be termed a "value-based healthcare practice redesign", which encompasses the initial steps that orthopaedic practices can begin with during their transition from traditional care toward value-based care. [Extracted from the article]

Shared decision-making (SDM) is a collaborative process wherein clinicians share their knowledge of conditions, treatment options, and potential harms and benefits, and patients share their preferences, values, and goals before making individualized and confident healthcare decisions together. My Patients Want Me to Make the Decision Surgeon perceptions of patient preferences and control over decision-making may be misaligned with patient perceptions, despite the availability of PROs and patient decision aids, which are intended to limit this mismatch [[1]]. Patient decision aids have been developed to facilitate SDM, and they have been shown to consistently improve a patient's knowledge about their condition and treatment options as well as decision quality, resulting in more informed and confident decisions [[5]]. [Extracted from the article]

The objective of this study was to assess the feasibility of using an electronic clinical quality measure (eCQM) to assess inpatient respiratory depression rates following elective primary total hip or total knee arthroplasty using data routinely collected in electronic health records. Measure testing was conducted at two large urban, academic health systems -- Mass General Brigham and a geographically distant system in southern U.S. The risk-adjusted inpatient respiratory depression rates were 3.83 and 2.73% for the two health systems, respectively. Clinician group rates ranged from 1.40 to 4.35%, demonstrating opportunity for improvement. Both the data and measure specifications showed strong reliability and validity to allow for calculation of accurate and comparable rates of inpatient respiratory depression. [ABSTRACT FROM AUTHOR]

This article discusses the concept of value-based healthcare and emphasizes that cost containment does not necessarily equal value creation. The authors highlight the increasing healthcare expenditures in the United States and other countries, without a corresponding improvement in health-related outcomes. They argue that cost-cutting measures should be focused on increasing value for patients, rather than simply reducing expenses. The authors recommend three principles for orthopedic leaders to consider before engaging in cost-cutting: measuring health and well-being before and after cost-cutting initiatives, targeting low-value care for cuts, and building trust during the cost-cutting process. They emphasize the importance of considering health outcomes and the well-being of patients and care delivery teams when determining the most appropriate approach to cost containment. [Extracted from the article]

Patient activation, the propensity for patients to engage in adaptive health behaviors, is a modifiable factor associated with health outcomes and treatment compliance. The authors evaluated the effect of a question-building intervention (QBI) on patient activation among patients with musculoskeletal symptoms and a low baseline level of activation. Patients seeking treatment for musculoskeletal pain were recruited at the beginning of their outpatient clinic appointment, and they completed the Patient Activation Measure 10-item version (PAM-10) and a demographic questionnaire. Those identified as low activating, based on the initial PAM-10 scores, completed a QBI protocol before their consultation with their provider. A follow-up PAM-10 survey was administered at the end of the visit. A paired sample Student's t test was used to evaluate preintervention and postintervention PAM-10 scores. Fisher's exact test and an unpaired t test were used to assess the association between demographic variables and achievement of minimal clinically important difference (MCID) for PAM-10. Of 194 patients who consented to participate, 60 were identified as low activating and completed the QBI. A paired Student's t test showed a statistically significant increase in mean PAM-10 scores from preintervention (47.3±7.4) to postintervention (54.8±16.8; P<.001). No statistically significant differences were shown in the likelihood of achieving MCID for PAM-10 scores for the sociodemographic variables that were tested. Low-activating patients may benefit from a simple question-formulating intervention before consultation with an orthopedic provider. [Orthopedics. 2021;44(5):e661-e667.]. [ABSTRACT FROM AUTHOR]

For example, should we define treatment success as the eradication of infection, increased objective function of the joint, or improvement of subjective patient-reported outcome measures? Mitigating the risk of postoperative complications has been a major focus of cost-control efforts for orthopaedic surgeons in the era of value-based healthcare (VBHC). [Extracted from the article]

These mid-career and senior professionals have the opportunity to guide new surgeons through professional challenges and provide advice for navigating career-related decision-making in preparation for coaching from a sponsor. Helping women achieve their professional potential in orthopaedic surgery is an important pillar of gender-based advocacy that not only benefits women but also adds value to the overall healthcare system - which helps all of us, and the patients whom we serve. Sponsorship by influential leaders invites women trainees and early career surgeons to the table, providing them fair access to the levers of organizational authority, which in turn, advances the field for other women surgeons and patients alike. [Extracted from the article]

Objective (SES) and subjective socioeconomic status (SSS) affect symptom intensity and magnitude of limitations. Identification of potentially modifiable social risk factors might contribute to additional opportunities for optimizing musculoskeletal health. (1) There are no correlations between magnitude of limitations (as measured with Patient-Reported Outcomes Measurement Information System Physical Function [PROMIS PF computer adaptive test]) and components of SES or SSS in people with musculoskeletal disease; (2) There are no factors (including level of social deprivation) independently associated with PROMIS PF. One hundred and fifty-nine patients presenting to clinicians specializing in the treatment of a broad variety of musculoskeletal conditions were prospectively enrolled in the study. We recorded patient demographics and assessed patients' socioeconomic status using the MacArthur Sociodemographic questionnaire and physical disability rating using PROMIS PF. Patients deprivation index was retrieved using their 9-digit ZIP codes. We used bivariate analysis to determine correlations between magnitude of limitations and socioeconomic status. We created a stepwise backward multivariable linear regression model to assess factors independently associated with PROMIS PF. Weak correlations were found on bivariate analysis of PROMIS PF with SSS measured as "Place in community" (r 0.28; P < 0.001) and "Place in the United States of America" (r 0.25; P = 0.002). In the multivariable models, the area deprivation index was not independently associated with physical limitations. Male gender (beta regression coefficient [β] 4.1; 95% CI 0.71 to 7.5; P = 0.018) and having net worth of $5000 - $19,999 (β 6.3; 95% CI 0.35 to 12; P = 0.038) or $20,000 - $99,999 (β 5.8; 95% CI 2.1 to 9.5; P = 0.003) when compared to having net worth of less than $4999 were independently associated with better physical function. Being unemployed or disabled and keeping house, being a student, or retired were independently associated with worse physical function (β −12; 95% CI -18 to −7.0; P < 0.001; β −5.6; 95% CI -9.9 to −1.4; P = 0.009, respectively), when compared to working full-time or part-time. Objective and subjective measures of socioeconomic status are associated with magnitude of physical limitations in patients with musculoskeletal illness. These factors should be considered when developing treatment plans for patients with musculoskeletal conditions. Level II prognostic study. [ABSTRACT FROM AUTHOR]

Patient-reported outcome measures (PROMs) are increasingly integrated into reporting requirements tied to reimbursement. There may be advantages to computer adaptive tests that apply to many different anatomical regions and diseases, provided that important information is not lost. 1) Does the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computer adaptive test correlate with the Hip injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR: a hip-specific PROM); 2) Is there any difference in the amount of variation explained by various factors (e.g. age, BMI, presence of concomitant knee pain) for both measures? In this prospective, cross-sectional study of 213 patients, we assessed the Pearson correlation of PROMIS PF and HOOS, JR. To investigate the variation explained by various patient-level factors, we constructed two multivariable linear regression models. We found a large correlation between PROMIS PF and HOOS, JR (r 0.58, P < 0.001). Disabled or unemployed status was independently associated with both lower PROMIS PF and HOOS, JR scores (regression coefficient [β] −3.4; 95% confidence interval [CI] −5.8 to −1.0; P = 0.006 and β −11; 95% CI -17 to −5.0; P < 0.001, respectively). Private rather than public insurance was associated with both higher PROMIS PF and HOOS, JR scores (β 4.5; 95% CI 2.2 to 6.8; P < 0.001 and β 6.4; 95% CI 0.49 to 12; P = 0.034, respectively). No floor or ceiling effects were observed for PROMIS PF. HOOS, JR scores showed 4.2% floor and 0.5% ceiling effect. This study adds to the evidence that general measures of physical limitations may provide similar information as joint- or region-specific measures. Level III. [ABSTRACT FROM AUTHOR]

Up to one‐third of total joint replacement (TJR) procedures may be performed inappropriately in a subset of patients who remain dissatisfied with their outcomes, stressing the importance of shared decision‐making. Patient‐reported outcome measures capture physical, emotional, and social aspects of health and wellbeing from the patient's perspective. Powerful computer systems capable of performing highly sophisticated analysis using different types of data, including patient‐derived data, such as patient‐reported outcomes, may eliminate guess work, generating impactful metrics to better inform the decision‐making process. We have created a shared decision‐making tool which generates personalized predictions of risks and benefits from TJR based on patient‐reported outcomes as well as clinical and demographic data. We present the protocol for a randomized controlled trial designed to assess the impact of this tool on decision quality, level of shared decision‐making, and patient and process outcomes. We also discuss current concepts in this field and highlight opportunities leveraging patient‐reported data and artificial intelligence for decision support across the care continuum. [ABSTRACT FROM AUTHOR]

Background: Prices for total joint arthroplasty vary widely. Insurers have experimented with reference-based benefit designs (reference pricing) to control costs by setting a contribution limit that covers lower-priced facilities but necessitates higher out-of-pocket payments at higher-priced facilities. The purpose of this study was to evaluate the impact of reference pricing on the cost and quality of care for total joint arthroplasty.Methods: The California Public Employees' Retirement System (CalPERS) implemented reference pricing for total joint arthroplasty in January 2011. We obtained data on 2,023 CalPERS patients who underwent total joint arthroplasty from January 2009 to December 2013 and comparison group data on 8,024 non-CalPERS patients from the same time period. Trends in 9 cost and quality-related metrics were compared between the CalPERS group and the comparison group: patient choice of a lower-priced hospital, insurer payment, consumer payment, 90-day complication rate, 90-day readmission rate, annual surgical volume of the chosen hospital, length of stay, travel distance, and rate of discharge to home. The impact of reference pricing was estimated with difference-in-differences multivariable regressions, adjusting for covariates.Results: An increase of 19 percentage points (95% confidence interval [CI], 13.0 to 25.6 percentage points; p < 0.01) in the selection of lower-priced hospitals was attributable to reference pricing, with a concurrent mean savings for the insurer of $5,067 (95% CI, $2,315 to $7,819; p < 0.01) and an increase in the mean patient out-of-pocket payment of $1,991 (95% CI, $1,053 to $2,929; p < 0.01). No significant change in any quality indicator was attributable to reference pricing, with the exception of an 8% reduction (95% CI, 3.3% to 12.7% reduction; p < 0.01) in the length of stay for hip replacement.Conclusions: Reference pricing motivates patients to choose lower-priced hospitals for total joint arthroplasty, with no measurable adverse impact on quality. Reference pricing represents a viable strategy in the shift toward value-based care. [ABSTRACT FROM AUTHOR]

Each team will look different from practice to practice depending on the specialty and patient population. Building the right musculoskeletal clinical team lays the foundation for a successful value-based healthcare (VBHC) practice. Having a team invested in effective care coordination, outcome measurement, and patient satisfaction required by VBHC practices demands structure and strong leadership. [Extracted from the article]

The article offers information on the artificial intelligence (AI) regarding providing value in orthopaedic surgery. Topics discussed include promise for enhancing predictive, diagnostic and decision-making capabilities; accelerating allure of AI in health care which has been fueled by growing datasets, algorithmic innovation, storage capacity and the steep rise in affordable computational power; and also mentions determining the risk of death after arthroplasty.

Background: Evaluation of total joint arthroplasty (TJA) patient-reported outcomes and survivorship requires that records of the index and potential revision arthroplasty procedure are reliably captured. Until the goal of the American Joint Replacement Registry (AJRR) of more-complete nationwide capture is reached, one must assume that patient migration from hospitals enrolled in the AJRR to nonAJRR hospitals occurs. Since such migration might result in loss to followup and erroneous conclusions on survivorship and other outcomes of interest, we sought to quantify the level of migration and identify factors that might be associated with migration in a specific AJRR population.Questions/purposes: (1) What are the out-of-state and within-state migration patterns of U.S. Medicare TJA patients over time? (2) What patient demographic and institutional factors are associated with these patterns?Methods: Hospital records of Medicare fee-for-service beneficiaries enrolled from January 1, 2004 to December 31, 2015, were queried to identify primary TJA procedures. Because of the nationwide nature of the Medicare program, low rates of loss to followup among Medicare beneficiaries, as well as long-established enrollment and claims processing procedures, this database is ideal for examining patient migration after TJA. We identified an initial cohort of 5.33 million TJA records from 2004 to 2016; after excluding patients younger than 65 years of age, those enrolled solely due to disability, those enrolled in a Medicare HMO, or residing outside the United States, the final analytical dataset consisted of 1.38 million THAs and 3.03 million TKAs. The rate of change in state or county of residence, based on Medicare annual enrollment data, was calculated as a function of patient demographic and institutional factors. A multivariate Cox model with competing risk adjustment was used to evaluate the association of patient demographic and institutional factors with risk of out-of-state or out-of-county (within-state) migration.Results: One year after the primary arthroplasty, 0.61% (95% confidence interval [CI], 0.60-0.61; p < 0.001 for this and all comparisons in this Results section) of Medicare patients moved out of state and another 0.62% (95% CI, 0.60-0.63) moved to a different county within the same state. Five years after the primary arthroplasty, approximately 5.41% (95% CI, 5.39-5.44) of patients moved out of state and another 5.50% (95% CI, 5.46-5.54) Medicare patients moved to a different county within the same state. Among numerous factors of interest, women were more likely to migrate out of state compared with men (hazard ratios [HR], 1.06), whereas black patients were less likely (HR, 0.82). Patients in the Midwest were less likely to migrate compared with patients in the South (HR, 0.74). Patients aged 80 and older were more likely to migrate compared with 65- to 69-year-old patients (HR, 1.19). Patients with higher Charlson Comorbidity Index scores compared with 0 were more likely to migrate (index of 5+; HR, 1.19).Conclusions: Capturing detailed information on patients who migrate out of county or state, with associated changes in medical facility, requires a nationwide network of participating registry hospitals. At 5 years from primary arthroplasty, more than 10% of Medicare patients were found to migrate out of county or out of state, and the rate increases to 18% after 10 years. Since it must be assumed that younger patients might exhibit even higher migration levels, these findings may help inform public policy as a "best-case" estimate of loss to followup under the current AJRR capture area. Our study reinforces the need to continue aggressive hospital recruitment to the AJRR, while future research using an increasingly robust AJRR database may help establish the migration patterns of nonMedicare patients.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Despite increasing interest in total joint arthroplasty registries, evidence of the impact of physician-level performance on the value of care provided to patients undergoing hip and knee arthroplasty is lacking. The purpose of this study was to examine the effectiveness of an unblinded orthopaedic surgeon-specific value scorecard in improving patient outcomes and reducing hospital costs.Methods: We retrospectively analyzed patient outcomes and hospital costs associated with total joint arthroplasties before and 9 months after the introduction of a Surgeon Value Scorecard at an urban tertiary care center. From August 2016 to May 2017, orthopaedic surgeons received an unblinded monthly Surgeon Value Scorecard summarizing a rolling 6-month view of results by surgeon for patients attributed to Diagnosis Related Group 470 (major lower-extremity arthroplasty without comorbidity or complication). Prior to implementation, surgeons were educated on the scorecard and participated in the development of a document outlining the definition and calculation of included metrics. Scorecard metrics were grouped into 5 categories: patient demographic characteristics, patient outcomes (for example, length of stay, discharge disposition, readmissions), patient experience, financial, and operational (for example, operative times). Financial (cost) measures and patient outcomes were selected as the key performance indicators analyzed in this study. Continuous variables were analyzed using the t test when a normal distribution was assumed and using Mann-Whitney tests when a non-normal distribution was assumed. Categorical variables were compared using chi-square tests. Significance was defined as p < 0.05.Results: After 9 months of unblinded Surgeon Value Scorecard distribution, the mean total costs for total joint arthroplasties decreased by 8.7%, from $17,996 to $16,426 (p < 0.001). The mean total direct variable costs decreased by 17.1% from $10,945 to $9,070 (p < 0.001), and implant costs decreased by 5.3% (p < 0.001). Length of stay also decreased by 0.2 day to 1.7 days (p < 0.001), and, although there was improvement in the home-discharge rate, 30-day readmission rate, and 90-day readmission rate, the differences were not significant (p > 0.05).Conclusions: The implementation of a surgeon-specific value scorecard for lower-extremity joint arthroplasties was associated with reduced total and direct variable hospital costs, reduced implant costs, decreased variation in costs, and reduced postoperative length of stay, without compromising clinical outcomes.Clinical Relevance: Sharing unblinded clinical and financial outcomes with surgeons may promote a culture of shared accountability and may empower surgeons to improve value-based decision-making in care delivery. [ABSTRACT FROM AUTHOR]

Background: Periprosthetic joint infection (PJI) following total knee arthroplasty is a growing concern, as the demand for total knee arthroplasty (TKA) expands annually. Although 2-stage revision is considered the gold standard in management, there is substantial morbidity and mortality associated with this strategy. One-stage revision is associated with lower mortality rates and better quality of life, and there has been increased interest in utilizing the 1-stage strategy. However, surgeons are faced with a difficult decision regarding which strategy to use to treat these infections, considering uncertainty with respect to eradication of infection, quality of life, and societal costs with each strategy. The purpose of the current study was to use decision analysis to determine the optimal decision for the management of PJI following TKA.Methods: An expected-value decision tree was constructed to estimate the quality-adjusted life-years (QALYs) and costs associated with 1-stage and 2-stage revision. Two decision trees were created: Decision Tree 1 was constructed for all pathogens, and Decision Tree 2 was constructed solely for difficult-to-treat infections, including methicillin-resistant infections. Values for parameters in the decision model, such as mortality rate, reinfection rate, and need for additional surgeries, were derived from the literature. Medical costs were derived from Medicare data. Sensitivity analysis determined which parameters in the decision model had the most influence on the optimal strategy.Results: In both decision trees, the 1-stage strategy produced greater health utility while also being more cost-effective. In the Monte Carlo simulation for Decision Trees 1 and 2, 1-stage was the dominant strategy in about 85% and 69% of the trials, respectively. Sensitivity analysis showed that the reinfection and 1-year mortality rates were the most sensitive parameters influencing the optimal decision.Conclusions: Despite 2-stage revision being considered the current gold standard for infection eradication in patients with PJI following TKA, the optimal decision that produced the highest quality of life was 1-stage revision. These results should be considered in shared decision-making with patients who experience PJI following TKA.Level Of Evidence: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article focuses on the value of the medical care provided against the cost of the services in the orthopaedics sector. It talks about the quality of the healthcare delivery improving in orthopaedics along with the rising medical care costs. It tells about the Time-driven activity-based costing (TDABC) accurately calculates the cost of the medical care service.

Value-based Healthcare: Health Literacy's Impact on Orthopaedic Care Delivery and Community Viability. [Extracted from the article]

Background: The American Joint Replacement Registry (AJRR) Total Joint Risk Calculator uses demographic and clinical parameters to provide risk estimates for 90-day mortality and 2-year periprosthetic joint infection (PJI). The tool is intended to help surgeons counsel their Medicare-eligible patients about their risk of death and PJI after total joint arthroplasty (TJA). However, for a predictive risk model to be useful, it must be accurate when applied to new patients; this has yet to be established for this calculator.Questions/purposes: To produce accuracy metrics (ie, discrimination, calibration) for the AJRR mortality calculator using data from Medicare-eligible patients undergoing TJA in the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States, where more than 10,000 TJAs are performed annually.Methods: We used the AJRR calculator to predict risk of death within 90 days of surgery among 31,214 VHA patients older than 64 years of age who underwent primary TJA; data was drawn from the Veterans Affairs Surgical Quality Improvement Project (VASQIP) and VA Corporate Data Warehouse (CDW). We then used VHA mortality data to evaluate the extent to which the AJRR calculator estimates distinguished individuals who died compared with those who did not (C-statistic), and graphically depicted the relationship between estimated risk and observed mortality (calibration). As a secondary evaluation of the calculator, a sample of 39,300 patients younger than 65 years old was assigned to the youngest age group available to the user (65-69 years) as might be done in real-world practice.Results: C-statistics for 90-day mortality for the older samples were 0.62 (95% CI, 0.60-0.64) and for the younger samples they were 0.46 (95% CI, 0.43-0.49), suggesting poor discrimination. Calibration analysis revealed poor correspondence between deciles of predicted risk and observed mortality rates. Poor discrimination and calibration mean that patients who died will frequently have a lower estimated risk of death than surviving patients.Conclusions: For Medicare-eligible patients receiving TJA in the VA, the AJRR risk calculator had a poor performance in the prediction of 90-day mortality. There are several possible reasons for the model's poor performance. Veterans Health Administration patients, 97% of whom were men, represent only a subset of the broader Medicare population. However, applying the calculator to a subset of the target population should not affect its accuracy. Other reasons for poor performance include a lack of an underlying statistical model in the calculator's implementation and simply the challenge of predicting rare events. External validation in a more representative sample of Medicare patients should be conducted to before assuming this tool is accurate for its intended use.Level Of Evidence: Level I, diagnostic study. [ABSTRACT FROM AUTHOR]

Health care has entered an era where value and quality have become more important than just quantity. Patient-reported outcomes are a critical aspect of the value equation. Orthopaedic surgeons will need to demonstrate that their treatment regimens actually are enhancing their patients' quality of life. In order to do this, the collection of prospective patient-reported outcome data will be critical. For most patients, this will require the use of a general health survey and a disease-specific questionnaire. Currently, most orthopaedic surgeons are not collecting this type of data. The questions are: What types of patient-generated questionnaires can provide the information needed, and how can these data be collected in a cost-effective manner? We will discuss what value means to payers and what the outcome measures are that are selected by various orthopaedic subspecialty societies to evaluate patients who undergo total hip and knee arthroplasty as well as patients with shoulder and knee problems, and we will review potential strategies to collect prospective patient-outcome data in a cost-effective manner in the office. [ABSTRACT FROM AUTHOR]

Background: The efficacy of corticosteroid and hyaluronic acid injections for knee osteoarthritis has been questioned. The purpose of this study was to determine the impact of the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines on the use of these injections in the United States and determine if utilization differed by provider specialty.Methods: Patients with knee osteoarthritis were identified within the Humana database from 2007 to 2015, and the percentage of patients receiving a knee injection relative to the number of patients having an encounter for knee osteoarthritis was calculated and was trended for the study period. The impact of each edition of the AAOS clinical practice guidelines on injection use was evaluated with segmented regression analysis. Injection trends were also analyzed relative to the specialty of the provider performing the injection.Results: Of 1,065,175 patients with knee osteoarthritis, 405,101 (38.0%) received a corticosteroid injection and 137,005 (12.9%) received a hyaluronic acid injection. The rate of increase in hyaluronic acid use, per 100 patients with knee osteoarthritis, decreased from 0.15 to 0.07 injection per quarter year (p = 0.02) after the first clinical practice guideline, and the increase changed to a decrease at a rate of -0.12 injection per quarter (p < 0.001) after the second clinical practice guideline. After the first clinical practice guideline, the rate of increase in utilization of corticosteroids, per 100 patients with knee osteoarthritis, significantly lessened to 0.12 injection per quarter (p < 0.001), and after the second clinical practice guideline, corticosteroid injection use plateaued (p = 0.72). The trend in use of hyaluronic acid injections by orthopaedic surgeons and pain specialists decreased with time following the second-edition clinical practice guideline but did not change for primary care physicians or nonoperative musculoskeletal providers.Conclusions: Subtle but significant changes in hyaluronic acid and corticosteroid injections occurred following the publication of both clinical practice guidelines. Although the clinical practice guidelines did impact injection use, given the high costs of these injections and their questionable clinical efficacy, further interventions beyond publishing clinical practice guidelines are needed to encourage higher-value care for patients with knee osteoarthritis. [ABSTRACT FROM AUTHOR]

Background: Use of large clinical and administrative databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and varies in their methodology of data acquisition, which makes it possible that similar research questions posed to different databases might result in answers that differ in important ways.Questions/purposes: (1) What are the differences in reported demographics, comorbidities, and complications for patients undergoing primary TKA among four databases commonly used in orthopaedic research? (2) How does the difference in reported complication rates vary depending on whether only inpatient data or 30-day postoperative data are analyzed?Methods: Patients who underwent primary TKA during 2010 to 2012 were identified within the National Surgical Quality Improvement Programs (NSQIP), the Nationwide Inpatient Sample (NIS), the Medicare Standard Analytic Files (MED), and the Humana Administrative Claims database (HAC). NSQIP is a clinical registry that captures both inpatient and outpatient events up to 30 days after surgery using clinical reviewers and strict definitions for each variable. The other databases are administrative claims databases with their comorbidity and adverse event data defined by diagnosis and procedure codes used for reimbursement. NIS is limited to inpatient data only, whereas HAC and MED also have outpatient data. The number of patients undergoing primary TKA from each database was 48,248 in HAC, 783,546 in MED, 393,050 in NIS, and 43,220 in NSQIP. NSQIP definitions for comorbidities and surgical complications were matched to corresponding International Classification of Diseases, 9 Revision/Current Procedural Terminology codes and these coding algorithms were used to query NIS, MED, and HAC. Age, sex, comorbidities, and inpatient versus 30-day postoperative complications were compared across the four databases. Given the large sample sizes, statistical significance was often detected for small, clinically unimportant differences; thus, the focus of comparisons was whether the difference reached an absolute difference of twofold to signify an important clinical difference.Results: Although there was a higher proportion of males in NIS and NSQIP and patients in NIS were younger, the difference was slight and well below our predefined threshold for a clinically important difference. There was variation in the prevalence of comorbidities and rates of postoperative complications among databases. The prevalence of chronic obstructive pulmonary disease (COPD) and coagulopathy in HAC and MED was more than twice that in NIS and NSQIP (relative risk [RR] for COPD: MED versus NIS 3.1, MED versus NSQIP 4.5, HAC versus NIS 3.6, HAC versus NSQIP 5.3; RR for coagulopathy: MED versus NIS 3.9, MED versus NSQIP 3.1, HAC versus NIS 3.3, HAC versus NSQIP 2.7; p < 0.001 for all comparisons). NSQIP had more than twice the obesity as NIS (RR 0.35). Rates of stroke within 30 days of TKA had more than a twofold difference among all databases (p < 0.001). HAC had more than twice the rates of 30-day complications at all endpoints compared with NSQIP and more than twice the 30-day infections as MED. A comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of wound infections and deep vein thromboses is captured when data are analyzed out to 30 days after TKA (p < 0.001 for all comparisons).Conclusions: When evaluating research utilizing large databases, one must pay particular attention to the type of database used (administrative claims, clinical registry, or other kinds of databases), time period included, definitions utilized for specific variables, and the population captured to ensure it is best suited for the specific research question. Furthermore, with the advent of bundled payments, policymakers must meticulously consider the data sources used to ensure the data analytics match historical sources.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: For patients with failed surgical treatment of an infected TKA, salvage operations such as arthrodesis or above-knee amputation (AKA) may be considered. Clinical and institutional factors associated with AKA and arthrodesis after a failed TKA have not been investigated in a large-scale population, and the utilization rate and trend of these measures are not well known.Questions/purposes: (1) How has the frequency of arthrodesis and AKA after infected TKA changed over the last 10 years? (2) What clinical or institutional factors are associated with patients undergoing arthrodesis or AKA? (3) What is the risk of mortality after arthrodesis or AKA?Methods: The Medicare 100% National Inpatient Claims Database was used to identify 44,466 patients 65 years of age or older who were diagnosed with an infected TKA and who underwent revision between 2005 and 2014 based on International Classification of Diseases, 9th Revision, Clinical Modification codes. Overall, 1182 knee arthrodeses and 1864 AKAs were identified among the study population. One year of data before the index infection-related knee revision were used to examine patient demographic, institutional, and clinical factors, including comorbidities, hospital volumes, and surgeon volumes. We developed Cox regression models to investigate the risk of arthrodesis, AKA, and death as outcomes. In addition, the year of the index revision was included as a covariate to determine if the risk of subsequent surgical interventions was changing over time. The risk of mortality was also assessed as the event of interest using a similar multivariate Cox model for each patient group (arthrodesis, AKA) in addition to those who underwent additional revisions but who did not undergo either of the salvage procedures.Results: The number of arthrodesis (hazard ratio [HR], 0.90, p < 0.001) and amputation (HR, 0.95, p < 0.001) procedures showed a declining trend. Clinical factors associated with arthrodesis included acute renal failure (HR, 1.22 [1.06-1.41], p = 0.006), obesity (HR, 1.58 [1.35-1.84], p < 0.001), and having additional infection-related revisions (HR for 2+ additional revisions, 1.36 [1.13-1.64], p = 0.001). Higher Charlson comorbidity score (HR for a score of 5+ versus 0, 2.56 [2.12-3.14], p < 0.001), obesity (HR, 1.14 [1.00-1.30], p = 0.044), deep vein thrombosis (HR, 1.34 [1.12-1.60], p = 0.001), and additional revisions (HR for 2+ additional revisions, 2.19 [1.91-2.49], p < 0.001) were factors associated with AKA, which in turn was an independent risk factor for mortality. The risk of death increased with amputation after adjusting for age, comorbidities, and other factors (HR, 1.28 [1.20-1.37], p < 0.001), but patients who received arthrodesis did not show a change in mortality compared with the patients who did not receive arthrodesis or amputation (HR, 1.00 [0.91-1.10], p = 0.971).Conclusions: The findings of this study suggest that clinicians may be more aggressively attempting to preserve the knee even in the face of chronic prosthetic joint infection but also show that a greater number of revisions is associated with a greater risk of subsequent AKA or arthrodesis. The results also suggest that recommending centers with a high volume of joint arthroplasties may be a way to reduce the risk of the salvage procedures.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]