Payment drivers in Medicare patients undergoing total ankle arthroplasty

Category: Ankle Arthritis Introduction/Purpose: The Comprehensive Care for Joint Replacement model (CJR) provides bundled payments for in-hospital and 90-day post-discharge care of patients undergoing total ankle arthroplasty (TAA). Defining patient factors associated with increased costs during TAA could help refine patient selection strategies and identify modifiable preoperative patient factors that can be addressed prior to the patient entering the bundle. Methods: This study is part of an IRB-approved single-center observational study of patients undergoing TAA from 1/1/2012 to 12/15/2016. Patients were included if they met CJR criteria for inclusion into the bundled payment model and had Medicare as the insurance payer. Costs related to readmissions, diagnosis, and procedures that had been excluded by CJR were also excluded from this financial analysis. All inpatient and outpatient payments beginning at the index procedure through 90 days postoperatively were identified. Patient medical profile including Charlson-Deyo and Elixhauser comorbidity scores, preoperative comorbidities, and perioperative factors were then completed based on institutional data and chart review. Additionally, post-discharge disposition, readmissions, emergency department (ED) utilization, and outpatient plastic surgery consultation were recorded within the 90-day bundled payment period. Results: Out of 199 patients with Medicare payments in the study timeframe, 137 had consented to the study and were analyzed. Baseline and operative characteristics are given in Table 1. Increased length of stay (LOS) at the initial procedure, increased Charlson-Deyo comorbidity score, cerebrovascular disease, and peripheral vascular disease were significantly associated with higher payments. Discharge to skilled nursing facility (skilled nursing facility), admissions, ED visits, and wound complications were significant drivers of payment. Conclusion: Increased Charlson-Deyo score and vascular disease along with increased LOS were associated with increased payments from Medicare. Discharge to SNF, readmission, ED visits, and wound complications considerably increased payments. This study identifies the relationship between patient profile and increased financial burden, highlighting the potential utility of pre-operative mitigation of modifiable risk factors and stratification of payments based on patient profile. Lastly, reducing rates of SNF placement, readmission, ED visitation, and wound complications are targets for decreasing costs for patients undergoing TAA

Do Patient Risk Factors Impact 90-Day Readmission after Total Ankle Arthroplasty?

Category: Ankle,Ankle Arthritis Introduction/Purpose: The Comprehensive Care for Joint Replacement model (CJR) provides bundled payments for in-hospital and 90-day post-discharge care of patients undergoing lower extremity joint replacement including hip, knee, and ankle arthroplasty (THA, TKA, and TAA). Pre-operative risk factors influencing in-hospital and post-discharge costs are, thus, of keen interest. While THA and TKA have been reported to have a 5.3% 90-day readmission rate associated with race, gender, increased BMI, >2 medical comorbidities, increased length of stay, and discharge to inpatient rehab, little is known about factors that influence readmission rates after TAA. The purpose of this study is to identify risk factors associated with 90-day readmission after TAA. Methods: 1,048 patients undergoing TAA (ICD-9 81.56 or ICD-10 0SRF/G) at a single academic institution were prospectively enrolled into an ongoing, IRB-approved longitudinal TAR outcome study between 2007 and 2016. Records were retrospectively reviewed to determine patient, operative, and post-operative characteristics including age, gender, race, risk factors of the Charlson-Deyo comorbidity and Elixhauser indices, post-discharge disposition, BMI, length of stay, and ASA score. Pre-operative Elixhauser and Charlson-Deyo comorbidities were recorded using standardized ICD-9 and ICD-10 codes. Univariate tests of significance (t-tests for continuous inputs and chi-square tests for categorical inputs) were performed to determine the potential relationship between patient characteristics and 90-day readmission using JMP Pro version 13.0.0. The tables display pre-operative cohort-level and outcome-specific patient characteristics as well as the results of significance testing for comorbidities with >1% prevalence. Results: Thirty of 1048 (2.9%) patients were readmitted after TAA during the 90 day post-discharge window. Twenty-two (73%) of the patients were readmitted for surgical wound complication. The majority of the remaining 8 admissions were for medical illnesses not clearly related to the index procedure. Prevalent comorbidities included hypertension, cardiac arrhythmias, depression, obesity, rheumatoid arthritis, diabetes, hypothyroidism, and chronic obstructive pulmonary disease. However, there were no significant differences in patient characteristics between those who were readmitted and those who were not readmitted although patients that were readmitted tended to be slightly older, were less likely to be discharged to SNF or in-hospital rehabilitation, and had higher ASA score and Charlson-Deyo comorbidity index. No individual patient comorbidities were statistically associated with 90-day readmission. Conclusion: The 90-day readmission rate of 2.9% after TAA at our institution is lower than reported rates for THA and TKA nationally (5.3%). Although our patient population had a similar prevalence of risk factors when compared to THA/TKA patients, none of these factors were significantly associated with 90-day readmission. These data suggest that grouping TAA with THA and TKA for CJR may not be advisable. In an emerging era of bundled payments, further work is needed to delineate factors strongly associated with costly readmissions specific to surgical treatment and individualized based on pre-operative patient profile

Management of the Stiff Shoulder With Arthroscopic Circumferential Capsulotomy and Axillary Nerve Release

Management of the stiff shoulder is a common and frequently daunting clinical scenario. Arthroscopic capsular release is usually an option for management of severe, chronic glenohumeral joint contractures when conservative treatment fails. Technical hurdles including a thickened capsule, reduction in joint volume, and difficulty with positioning the shoulder intraoperatively can make this procedure challenging. In addition, incomplete release and recalcitrant stiffness are frequent issues. We believe a complete release of the capsule entails special attention to the axillary pouch and requires identification and protection of the axillary nerve. We present a technique for a complete arthroscopic circumferential capsulotomy and detail our approach to safely dissect and protect the axillary nerve under arthroscopic visualization

Capsular Suspension Technique for Hip Arthroscopy

Hip arthroscopy has recently become a common procedure to treat central and peripheral hip pathology. Capsulotomies are necessary in these procedures, and negotiating adequate visualization, as well as capsular preservation, is a challenge. We describe a capsular suspension technique that allows for adequate visualization of the central and peripheral compartments while facilitating preservation of the native hip capsule. This technique eliminates the need for additional personnel for retraction, potentially decreases iatrogenic hip injury, eliminates the need for excessive capsular debridement, and allows for capsular closure under minimal tension

General Assembly, Prevention, Operating Room - Surgical Attire: Proceedings of International Consensus on Orthopedic Infections

Delphi consensus on PJI of the hi