Conversion Total Knee Arthroplasty Needs Its Own Diagnosis Related Group Facility Reimbursement Code

Introduction: Conversion from a prior surgery to a total knee arthroplasty (TKA) is a more technically difficult procedure than primary TKA and is associated with worse short-term outcomes and increased complication and readmission rates, despite being undifferentiated under the current bundled payment model. The aim of this study was to determine differences in facility costs between primary TKA and conversion TKA, which we hypothesize are significant, to ensure providers are not penalized for treatment and high-risk patients have the same access to care. Methods: We retrospectively reviewed a consecutive series of patients undergoing primary TKA at two hospitals within Rothman Orthopaedic Institute from 2015-2017, comparing itemized facility costs between primary and conversion TKA patients. Secondary endpoints included length of stay, discharge disposition, and additional implants used. A multivariate regression analysis was performed to identify independent risk factors for increased facility costs, the need for additional implants, length of stay, and discharge disposition. Results: Of 2447 primary TKA procedures, 678 (27.7%) underwent conversion to TKA, which was associated with greater implant costs ($3424.25 vs. 3272.29, P\u3c0.0001), preoperative personnel costs ($1269.89 vs. $1217.72, p\u3c0.0001), and total costs ($6859.16 vs. $6703.55, p=0.0015). Presence of prior surgical hardware was a risk factor for increased implant costs ($501.1 increase, p=0.0024) and total cost ($501.4 increase, p=0.0024). Discussion: Conversion TKA is associated with significantly greater facility costs than primary TKA, thus confirming our hypothesis, and should be adjusted for in alternative payment models to ensure these patients do not encounter difficulties in accessing quality orthopaedic care

The Use of Cementless Components Does Not Significantly Increase Procedural Costs in Total Knee Arthroplasty

Introduction: Modern cementless total knee arthroplasty (TKA) designs have shown promising early clinical success; however, concerns exist regarding the higher cost of the cementless implants. The purpose of this study is to evaluate the total facility cost of cementless vs traditional cemented TKA along with the effect of cementless fixation on short-term outcomes. Methods: We reviewed a consecutive series of patients between 2015 and 2017 who underwent either cementless or cemented primary TKA. Itemized facility costs were calculated for every procedure using a time-driven activity-based costing algorithm. Controlling for demographic variables and medical comorbidities, we performed a multivariate analysis to identify independent risk factors for facility costs following TKA. Short-term outcome metrics including complications, readmissions, and patient-reported outcomes were compared between groups. Results: Among the 2426 primary TKA patients in this study, 119 (4.91%) were performed using cementless implants. When compared to cemented TKA, cementless TKA patients had higher implant costs, but lower supply costs and lower operating room personnel costs. When controlling for confounding variables, cementless fixation did not have a significant effect on total facility cost or outcomes. Discussion: The use of cementless TKA implants did not significantly increase total procedural costs when compared to traditional cemented TKA components at our institution. Our data suggest that the increased cost of a cementless implant is recouped through savings in cost of cement and supplies, as well as shorter operative times. The authors encourage investigators at other institutions to use the authors\u27 methodology to evaluate (preferably in a prospective manner) whether the findings from this study can be corroborated

Risk Factors and Effect of Acute Kidney Injury on Outcomes Following Total Hip and Knee Arthroplasty

Introduction: Development of acute kidney injury (AKI) following primary total joint arthroplasty (TJA) is a potentially avoidable complication associated with negative outcomes including increased length of stay and mortality. The purpose of this study was to determine the effect of AKI on short-term outcomes and identify risk factors for developing AKI following either total hip or total knee arthroplasty. It was hypothesized that AKI has significant adverse effects on short-term outcomes metrics. Methods: Patients undergoing primary TJA at a single hospital from 2005 to 2017 were identified and patient demographics, comorbidities, short-term outcomes, and perioperative laboratory results were recorded. AKI was defined as an increase in creatinine levels by 50% or 0.3 points. Demographics, comorbidities, and outcomes were compared between patients who developed AKI and those who did not. Multivariate regressions identified the independent effect of AKI on outcomes. Results: In total, 814 (3.9%) of 20,800 patients developed AKI. AKI independently increased length of stay by 0.26 days (P \u3c .001), in-hospital complication risk (odds ratio = 1.73,P \u3c .001), and discharge to facility risk (odds ratio = 1.26, P = .012). Potentially modifiable variables including body mass index, perioperative hemoglobin levels, surgery duration, and operative fluids administered were predicative of AKI. Discussion: AKI following TJA has significant adverse effects on outcomes including length of stay, discharge, and complications. Although many identified risk factors are nonmodifiable, maintaining adequate renal perfusion through optimizing preoperative hemoglobin, sufficient fluid resuscitation, and reducing blood loss may aid in mitigating the risk of developing AKI

Cardiac autonomic testing and treating heart disease. 'A clinical perspective'

Background Coronary heart disease (CHD) is a major health concern, affecting nearly half the middle-age population and responsible for nearly one-third of all deaths. Clinicians have several major responsibilities beyond diagnosing CHD, such as risk stratification of patients for major adverse cardiac events (MACE) and treating risks, as well as the patient. This second of a two-part review series discusses treating risk factors, including autonomic dysfunction, and expected outcomes. Methods Therapies for treating cardiac mortality risks including cardiovascular autonomic neuropathy (CAN), are discussed. Results While risk factors effectively target high-risk patients, a large number of individuals who will develop complications from heart disease are not identified by current scoring systems. Many patients with heart conditions, who appear to be well-managed by traditional therapies, experience MACE. Parasympathetic and Sympathetic (P&S) function testing provides more information and has the potential to further aid doctors in individualizing and titrating therapy to minimize risk. Advanced autonomic dysfunction (AAD) and its more severe form cardiovascular autonomic neuropathy have been strongly associated with an elevated risk of cardiac mortality and are diagnosable through autonomic testing. This additional information includes patient-specific physiologic measures, such as sympathovagal balance (SB). Studies have shown that establishing and maintaining proper SB minimizes morbidity and mortality risk. Conclusions P&S testing promotes primary prevention, treating subclinical disease states, as well as secondary prevention, thereby improving patient outcomes through (1) maintaining wellness, (2) preventing symptoms and disorder and (3) treating subclinical manifestations (autonomic dysfunction), as well as (4) disease and symptoms (autonomic neuropathy)

Cardiac autonomic testing and diagnosing heart disease. 'A clinical perspective'

Background Coronary heart disease (CHD) is a major health concern, affecting nearly half the middle-age population and responsible for nearly one-third of all deaths. Clinicians have responsibilities beyond diagnosing CHD, including risk stratification of patients for major adverse cardiac events (MACE), modifying the risks and treating the patient. In this first of a two-part review, identifying risk factors is reviewed, including more potential benefit from autonomic testing. Methods Traditional and non-traditional, and modifiable and non-modifiable risk factors for MACE where compared, including newer risk factors, such as inflammation, carotid intimal thickening, ankle-brachial index, CT calcium scoring, and autonomic function testing, specifically independent measurement of parasympathetic and sympathetic (P&S) activity. Results The Framingham Heart Study, and others, have identified traditional risk factors for the development of CHD. These factors effectively target high-risk patients, but a large number of individuals who will develop CHD and MACE are not identified. Many patients with CHD who appear to be well-managed by traditional therapies still experience MACE. In order to identify these patients, other possible risk factors have been explored. Advanced autonomic dysfunction, and its more severe form, cardiac autonomic neuropathy, have been strongly associated with an elevated risk of cardiac mortality and are diagnosable through P&S testing. Conclusions Independent measures of P&S activity, provides additional information and has the potential to incrementally add to risk assessment. This additional information enables physicians to (1) specifically target more high-risk patients and (2) titrate therapies, with autonomic testing guidance, in order to minimize risk of cardiac mortality and morbidity

Melatonin Does Not Improve Sleep Quality in a Randomized Placebo-controlled Trial After Primary Total Joint Arthroplasty.

INTRODUCTION: Sleep disturbance is a common concern among patients who have undergone total joint arthroplasty (TJA). Poor sleep during the postoperative period affect quality of life directly and may influence pain recovery after TJA. The purpose of this prospective study was to investigate whether the daily use of exogenous melatonin for 6 weeks after TJA can mitigate the effects of TJA on sleep. METHODS: A cohort of 118 patients undergoing primary total hip arthroplasty or total knee arthroplasty from 2018 to 2020 were randomized to melatonin (6 mg) or placebo for 42 days after surgery. Inclusion criterion was patients undergoing unilateral primary TJA. Patients who underwent bilateral TJA and revision TJA, with a history of sleep disturbance, and on opioid medication or sleep aids preoperatively were excluded. Sleep quality was assessed at baseline and at 2 and 6 weeks postoperatively using the validated self-administered questionnaire, Pittsburgh Sleep Quality Index (PSQI). Continuous and categorical variables were analyzed using Student t-test and chi-square analysis, respectively. Multivariate linear regression analysis was also conducted. RESULTS: Patients in both groups exhibited higher PSQI scores, representing lower sleep quality, at both 2 and 6 weeks postoperatively compared with that at baseline. Overall, global PSQI scores were 6.8, 9.8, and 8.8 at baseline, week 2, and week 6, respectively. No significant differences were noted between melatonin and placebo groups at baseline (6.8 versus 6.8, P = 0.988), week 2 (10.2 versus 9.3, P = 0.309), or week 6 (8.8 versus 8.7, P = 0.928). In multivariable regression, the only significant predictors of increased PSQI scores were an elevated baseline PSQI score (at both time points), a decreased length of stay (at week 2 only), and patients undergoing total hip arthroplasty versus total knee arthroplasty (at week 6 only). CONCLUSION: Patients undergoing TJA had poor sleep quality both preoperatively and postoperatively. The use of exogenous melatonin did not demonstrate any notable effect on sleep quality

Improved Patient Outcomes by Normalizing Sympathovagal Balance: Differentiating Syncope—Precise Subtype Differentiation Leads to Improved Outcomes

Syncope is difficult to definitively diagnose, even with tilt-table testing and beat-to-beat blood pressure measurements, the gold-standard. Both are qualitative, subjective assessments. There are subtypes of syncope associated with autonomic conditions for which tilt-table testing is not useful. Heart rate variability analyses also include too much ambiguity. Three subtypes of syncope are differentiated: vasovagal syncope (VVS) due to parasympathetic excess (VVS-PE), VVS with abnormal heart rate response (VVS-HR), and VVS without PE (VVS-PN). P&S monitoring (ANSAR, Inc., Philadelphia, PA) differentiates subtypes in 2727 cardiology patients (50.5% female; average age: 57 years; age range: 12–100 years), serially tested over four years (3.3 tests per patient, average). P&S monitoring noninvasively, independently, and simultaneously measures parasympathetic and sympathetic (P&S) activity, including the normal P-decrease followed by an S-increase with head-up postural change (standing). Syncope, as an S-excess (SE) with stand, is differentiated from orthostatic dysfunction (e.g., POTS) as S-withdrawal with stand. Upon standing, VVS-PE is further differentiated as SE with PE, VVS-HR as SE with abnormal HR, and VVS-PN as SE with normal P- and HR-responses. Improved understanding of the underlying pathophysiology by more accurate subtyping leads to more precise therapy and improved outcomes