Joseph A. Bosco

Cost Burden of 30-Day Readmissions Following Medicare Total Hip and Knee Arthroplasty

The Centers for Medicare and Medicaid Services has proposed bundling of payments for acute care episodes for certain procedures, including total joint arthroplasty. The purpose of this study is to quantify the readmission burden of TJA as a function of readmission rate and reimbursement for the bundled payment. Using the hospitals administrative database, we identified all unplanned 30-day readmissions following index admissions for total hip and total knee arthroplasty, and revision hip and knee arthroplasty among Medicare beneficiaries from 2009 to 2012. For each group, we determined 30-day readmission rates and direct costs of each readmission. The hospital cost margins for Medicare TJAs are small and any decrease in these margins can potentially make performing these procedures economically unfeasible potentially decreasing Medicare patient access.

An Analysis of Causes of Readmission After Spine Surgery

Study Design. Retrospective review of medical records. Objective. We reviewed all early readmissions after elective spine surgery at a single orthopedic specialty hospital to analyze the causes of unplanned readmissions. Summary of Background Data. Recent advances in techniques and instrumentation have made more complex spinal surgeries possible, although sometimes with more complications. Early readmission rate is being used as a marker to evaluate quality of care. There is little data available regarding the causes of early readmissions after spine surgery. Methods. Using the hospitals administrative database of patient records from 2007 to 2009, all patients who underwent spine surgery and were readmitted to the hospital within 30 days were identified and broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Analysis was focused on 12 common spine procedures based on the principle procedure International Classification of Diseases, Ninth Revision, Clinical Modification code for the patients initial admission. The readmission rate was calculated for each procedure. Results. A total of 156 early readmissions were identified, of which 141 were unplanned. Of the unplanned readmissions, the most common causes were infection or a concern for an infection (45 patients, 32% of unplanned readmissions), nonsurgical complications (31 patients, 22% of readmissions), complications requiring surgical revision (21 patients, 15% of readmissions), and wound drainage (12 patients, 9% of readmissions). Fifty-seven percent of unplanned readmissions required a return to the operating room (76% of infections or concern for infection). The average length of stay for the unplanned readmissions was 6.5 days. When using the 12 most common procedures based on the International Classification of Diseases, Ninth Revision, Clinical Modification, the early readmission rate was 3.8% (141 early readmissions in 3673 procedures). Conclusion. Infection, medical complications after surgery, and surgical complications requiring revision of implants are the primary causes of unplanned early readmissions and spine surgery. Further studies are necessary to identify patients and procedures most associated with readmission.

Cost-Effectiveness Analysis of Custom Total Knee Cutting Blocks

The purposes of this study were to examine the cost-effectiveness of this technology and to determine improvements in patient outcome needed to make custom total knee cutting blocks cost-effective. A Markov decision model was used to evaluate the cost-effectiveness of custom cutting blocks compared with traditional instrumentation in total knee arthroplasty. The analysis demonstrates routine use of custom cutting blocks for total knee arthroplasty will not be cost-effective unless it results in a significantly reduced revision rate. The reduction necessary increases with increasing costs for the custom blocks. Further research will be necessary to determine if this can be achieved using custom cutting blocks. Patients, surgeons, payers, and institutions should consider this when determining their support of this technology in the absence of supportive data.

The Effect of Discharge Disposition on 30-Day Readmission Rates After Total Joint Arthroplasty

Previous studies have demonstrated no significant difference in overall functional outcomes of patients discharged to a sub acute setting versus home with health services after total joint arthroplasty. These findings coupled with pressure to reduce health care costs and the implementation of a prospective payment system under Medicare have supported the use of home rehabilitation services and the trend towards earlier discharge after hospitalization. While the overall functional outcome of patients discharged to various settings has been studied, there is a relative dearth of investigation comparing postoperative complications and readmission rates between various discharge dispositions. Our study demonstrated patients discharged home with health services had a significantly lower 30 day readmission rate compared to those discharged to inpatient rehab facilities. Patients discharged to rehab facilities have a higher incidence of comorbidity and this association could be responsible for their higher rate of readmission.

Treatment of medial collateral ligament injuries.

&NA; The medial collateral ligament is the most frequently injured ligament of the knee. The anatomy and biomechanical role of this ligament and the associated posteromedial structures of the knee continue to be explored. Prophylactic knee bracing has shown promise in preventing injury to the medial collateral ligament, although perhaps at the cost of functional performance. Most isolated injuries are treated nonsurgically. Recent studies have investigated ligament‐healing variables, including modalities such as ultrasound and nonsteroidal anti‐inflammatory drugs. Concomitant damage to the anterior or posterior cruciate ligaments is a common indication to surgically address the high‐grade medial collateral ligament injury. The optimal treatment of multiligamentous knee injuries continues to evolve, and controversy exists surrounding the role of medial collateral ligament repair/reconstruction, with data supporting both conservative and surgical management.

Preventing Surgical Site Infections: A Randomized, Open-Label Trial of Nasal Mupirocin Ointment and Nasal Povidone-Iodine Solution

BACKGROUND Treatment of Staphylococcus aureus colonization before surgery reduces risk of surgical site infection (SSI). The regimen of nasal mupirocin ointment and topical chlorhexidine gluconate is effective, but cost and patient compliance may be a barrier. Nasal povidone-iodine solution may provide an alternative to mupirocin. METHODS We conducted an investigator-initiated, open-label, randomized trial comparing SSI after arthroplasty or spine fusion in patients receiving topical chlorhexidine wipes in combination with either twice daily application of nasal mupirocin ointment during the 5 days before surgery or 2 applications of povidone-iodine solution into each nostril within 2 hours of surgical incision. The primary study end point was deep SSI within the 3 months after surgery. RESULTS In the modified intent-to-treat analysis, a deep SSI developed after 14 of 855 surgical procedures in the mupirocin group and 6 of 842 surgical procedures in the povidone-iodine group (P = .1); S. aureus deep SSI developed after 5 surgical procedures in the mupirocin group and 1 surgical procedure in the povidone-iodine group (P = .2). In the per protocol analysis, S. aureus deep SSI developed in 5 of 763 surgical procedures in the mupirocin group and 0 of 776 surgical procedures in the povidone-iodine group (P = .03). CONCLUSIONS Nasal povidone-iodine may be considered as an alternative to mupirocin in a multifaceted approach to reduce SSI. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01313182.

Cost-Effectiveness of a Staphylococcus aureus Screening and Decolonization Program for High-Risk Orthopedic Patients

We conducted a Markov decision analysis to assess the cost savings associated with a preoperative Staphylococcus aureus screening and decolonization program on 365 hip and knee arthroplasties and 287 spine fusions. A 2-way sensitivity analysis was also used to calculate the needed reduction in surgical site infections to make the program cost saving. If cost of treating an infected hip or knee arthroplasty is equal to the cost of a primary knee arthroplasty, then the screening program needs to result in a 35% reduction in the revision rate, or a relative revision rate of 65% for patients in the screening program, to be cost saving. For spine fusions, the reduction in the revision rate to make the program cost saving is only 10%. Universal Staphylococcus aureus screening and decolonization for hip and knee arthroplasty and spinal fusion patients needs to result in only a modest reduction in the surgical site infection rate to be cost saving.

Management of Modifiable Risk Factors Prior to Primary Hip and Knee Arthroplasty: A Readmission Risk Assessment Tool.

BACKGROUND Preoperative risk stratification and optimization of preoperative care may be helpful in reducing readmission rates after primary total joint arthroplasty. Assessment of the predictive value of individual modifiable risk factors without a tool to assess cumulative risk may not provide proper risk stratification of patients with regard to potential readmissions. As part of a Perioperative Orthopaedic Surgical Home model, we developed a scoring system, the Readmission Risk Assessment Tool (RRAT), which allows for risk stratification in patients undergoing elective primary total joint arthroplasty at our institution. The purpose of this study was to analyze the relationship between the RRAT score and readmission after primary hip or knee arthroplasty. METHODS The RRAT, which is scored incrementally on the basis of the number and severity of modifiable comorbidities, was used to generate readmission scores for a cohort of 207 readmitted patients and two cohorts (one random and one age-matched) of 234 non-readmitted patients each. Regression analysis was performed to assess the strength of association of individual risk factors and the RRAT score with readmissions. We also calculated the odds and odds ratio (OR) at each RRAT score level to identify patients with relatively higher risk of readmission. RESULTS There were 207 (2.08%) readmissions among 9930 patients over a six-year period (2008 through 2013). Surgical site infection was the most common cause of readmission (ninety-three cases, 45%). The median RRAT scores were 3 (IQR [interquartile range], 1 to 4) and 1 (IQR, 0 to 2) for readmitted and non-readmitted groups, respectively. An RRAT score of ≥3 was significantly associated with higher odds of readmission. CONCLUSIONS Population health management, cost-effective care, and optimization of outcomes to maximize value are the new maxims for health-care delivery in the United States. We found that the RRAT score had a significant association with readmission after joint arthroplasty and could potentially be a clinically useful tool for risk mitigation.

Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data.

EXECUTIVE SUMMARY The rate of unplanned 30‐day readmissions to the hospital after discharge is being used as a marker to compare the quality of care across hospitals and to set reimbursement levels for care. While the readmission rate can be reported using administrative data, the accuracy of these data is variable, and defining which readmissions are unplanned and preventable is often difficult. The purpose of this study was to review readmissions to a single orthopedic hospital to identify the causes for readmission and, in particular, which readmissions are planned versus unplanned. Using that hospitals administrative database of patient records from 2007 to 2009, we identified all patients who were readmitted to the hospital within 30 days of a previous hospitalization for a procedure. Readmissions were broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined as either surgical or nonsurgical complications (medical conditions not directly related to the procedure). Almost 30 percent of readmissions were planned. Of the unplanned readmissions, close to 60 percent were triggered by an infection or a concern for an infection. Nonsurgical complications accounted for 18.2 percent of unplanned readmissions. This study highlights the importance of careful data collection and abstraction when calculating early readmission rates. Preventing surgical site infection and better coordinating care between orthopedic surgeons and primary care and medical subspecialty physicians may significantly reduce readmission rates.

Prevalence of Staphylococcus aureus colonization in orthopaedic surgeons and their patients: a prospective cohort controlled study.

BACKGROUND Methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus surgical site infections are an increasing health problem in the United States. To date, no study, as far as we know, has evaluated the prevalence of Staphylococcus aureus colonization in orthopaedic surgeons. The purpose of our study was to assess the prevalence of methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus colonization in orthopaedic surgery attending surgeons and residents at our institution compared with that in our high-risk patients. METHODS We performed nasal swab cultures in seventy-four orthopaedic attending surgeons and sixty-one orthopaedic surgery residents at our institution, screening for methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus. We compared these results with a prospective database of nasal cultures of patients undergoing joint replacement and spine surgery. RESULTS A total of 135 physicians were screened. Of those physicians, 1.5% were positive for methicillin-resistant Staphylococcus aureus and 35.7% were positive for methicillin-sensitive Staphylococcus aureus. None of the sixty-one residents were positive for methicillin-resistant Staphylococcus aureus. However, 59% were positive for methicillin-sensitive Staphylococcus aureus. Of the seventy-four attending surgeons, 2.7% were positive for methicillin-resistant Staphylococcus aureus and 23.3%, for methicillin-sensitive Staphylococcus aureus. Previous studies at our institution have demonstrated a 2.17% prevalence of nasal carriage of methicillin-resistant Staphylococcus aureus and an 18% rate of methicillin-sensitive Staphylococcus aureus in high-risk patients. Thus, no difference was found between the prevalence of methicillin-resistant Staphylococcus aureus in residents or attending surgeons and that in the high-risk patients. However, the prevalence of methicillin-sensitive Staphylococcus aureus colonization in the surgeons (35.7%) was significantly higher than that in the high-risk patient group (18%) (p < 0.01). CONCLUSIONS At a major teaching hospital, a higher prevalence of methicillin-sensitive Staphylococcus aureus colonization was found among attending and resident orthopaedic surgeons compared with a high-risk patient group, but the prevalence of methicillin-resistant Staphylococcus aureus colonization was similar.Background: Methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus surgical site infections are an increasing health problem in the United States. To date, no study, as far as we know, has evaluated the prevalence of Staphylococcus aureus colonization in orthopaedic surgeons. The purpose of our study was to assess the prevalence of methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus colonization in orthopaedic surgery attending surgeons and residents at our institution compared with that in our high-risk patients. Methods: We performed nasal swab cultures in seventy-four orthopaedic attending surgeons and sixty-one orthopaedic surgery residents at our institution, screening for methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus. We compared these results with a prospective database of nasal cultures of patients undergoing joint replacement and spine surgery. Results: A total of 135 physicians were screened. Of those physicians, 1.5% were positive for methicillin-resistant Staphylococcus aureus and 35.7% were positive for methicillin-sensitive Staphylococcus aureus. None of the sixty-one residents were positive for methicillin-resistant Staphylococcus aureus. However, 59% were positive for methicillin-sensitive Staphylococcus aureus. Of the seventy-four attending surgeons, 2.7% were positive for methicillin-resistant Staphylococcus aureus and 23.3%, for methicillin-sensitive Staphylococcus aureus. Previous studies at our institution have demonstrated a 2.17% prevalence of nasal carriage of methicillin-resistant Staphylococcus aureus and an 18% rate of methicillin-sensitive Staphylococcus aureus in high-risk patients. Thus, no difference was found between the prevalence of methicillin-resistant Staphylococcus aureus in residents or attending surgeons and that in the high-risk patients. However, the prevalence of methicillin-sensitive Staphylococcus aureus colonization in the surgeons (35.7%) was significantly higher than that in the high-risk patient group (18%) (p Conclusions: At a major teaching hospital, a higher prevalence of methicillin-sensitive Staphylococcus aureus colonization was found among attending and resident orthopaedic surgeons compared with a high-risk patient group, but the prevalence of methicillin-resistant Staphylococcus aureus colonization was similar.