Sergio M. Navarro

Evidence-based thresholds for the volume-value relationship in shoulder arthroplasty: outcomes and economies of scale

BACKGROUND Whereas several studies suggest that high-volume surgeons and hospitals deliver superior patient outcomes with greater cost efficiency, no evidence-based thresholds separating high-volume surgeons and hospitals from those that are low or medium volume exist in shoulder arthroplasty. The objective of this study was to establish meaningful thresholds that take outcomes and cost into consideration for surgeons and hospitals performing shoulder arthroplasty. METHODS Using 9546 patients undergoing primary shoulder arthroplasty for osteoarthritis from an administrative database, we created and applied 4 models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. We generated 4 sets of thresholds predictive of adverse outcomes, namely, increased length of stay (LOS) and increased cost for both surgeon and hospital volume. RESULTS SSLR analysis of the 4 ROC curves by surgeon volume produced 3 volume categories. LOS and cost by annual shoulder arthroplasty surgeon volume produced the same strata: 0-4 (low), 5-14 (medium), and 15 or more (high). LOS and cost by annual shoulder arthroplasty hospital volume produced the same strata: 0-3 (low), 4-14 (medium), and 15 or more (high). LOS and cost decreased significantly (P < .05) in progressively higher volume categories. CONCLUSIONS Our study validates economies of scale in shoulder arthroplasty by demonstrating a direct relationship between volume and value through SSLR analysis of ROC curves for risk-based volume stratification using meaningful volume definitions for low-, medium-, and high-volume surgeons and hospitals. The described volume-value relationship offers patients, surgeons, hospitals, and other stakeholders meaningful thresholds for the optimal delivery of shoulder arthroplasty.

The Patient Experience: An Analysis of Orthopedic Surgeon Quality on Physician-Rating Sites

BACKGROUND With the advent of the Consensus Core of Orthopedic Measures, arthroplasty surgeons are increasingly subjected to public performance reviews on physician-rating sites. Therefore, we evaluated (1) web site details of physician-rating sites, (2) differences between sites and the Consensus Core, (3) published patient experiences, (4) search rank among sites, and (5) differences between academic vs nonacademic and arthroplasty vs nonarthroplasty surgeons. METHODS The 5 busiest physician-rating sites were analyzed. To compare physician-rating sites to the Consensus Core, 3 reviewers analyzed the web site details. To evaluate patient ratings and reviews, orthopedists from the top 5 academic and nonacademic hospitals (2016 US News & World Report) were analyzed. Institution-produced rating sites were also analyzed. Findings were stratified between academic vs nonacademic and arthroplasty vs nonarthroplasty surgeons. Five hundred and six staff surgeons across 10 academic and nonacademic affiliated hospitals yielded 27,792 patient-generated ratings and reviews for 1404 accounts. RESULTS Features on all sites were practice location, languages spoken, and patient experience. Two sites autogenerated profiles of surgeons without consent. No physician-rating site contained all Consensus Core domains. The composite orthopedic surgeon rating was 4.1 of 5. No significant differences were found between academic and nonacademic affiliated surgeons. Arthroplasty surgeons had a greater number of reviews and ratings on 2 sites. CONCLUSION Reliability of physician-rating sites is questionable, as none contained all Consensus Core domains. Autogeneration of surgeon profiles is occurring, and no differences between academic vs nonacademic or arthroplasty vs nonarthroplasty surgeons were found. Institution-produced sites may serve to better promote and market surgeons.

Evidence-Based Thresholds for the Volume and Length of Stay Relationship in Total Hip Arthroplasty: Outcomes and Economies of Scale

BACKGROUND Several studies have indicated that high-volume surgeons and hospitals deliver higher value care. However, no evidence-based volume thresholds currently exist in total hip arthroplasty (THA). The primary objective of this study was to establish meaningful thresholds taking patient outcomes into consideration for surgeons and hospitals performing THA. A secondary objective was to examine the market share of THAs for each surgeon and hospital strata. METHODS Using 136,501 patients undergoing hip arthroplasty, we used stratum-specific likelihood ratio (SSLR) analysis of a receiver-operating characteristic curve to generate volume thresholds predictive of increased length of stay (LOS) for surgeons and hospitals. Additionally, we examined the relative proportion of annual THA cases performed by each surgeon and hospital strata established. RESULTS SSLR analysis of LOS by annual surgeon THA volume produced 3 strata: 0-69 (low), 70-121 (medium), and 121 or more (high). Analysis by annual hospital THA volume produced strata at: 0-120 (low), 121-357 (medium), and 358 or more (high). LOS decreased significantly (P < .05) in progressively higher volume categories. High-volume hospitals performed the majority of cases, whereas low-volume surgeons performed the majority of THAs. CONCLUSION Our study validates economies of scale in THA by demonstrating a direct relationship between volume and value for THA through risk-based volume stratification of surgeons and hospitals using SSLR analysis of receiver-operating characteristic curves to identify low-, medium-, and high-volume surgeons and hospitals. While the majority of primary THAs are performed at high-volume centers, low-volume surgeons are performing the majority of these cases, which may offer room for improvement in delivering value-based care.

Short-term Outcomes Following Concussion in the NFL: A Study of Player Longevity, Performance, and Financial Loss:

Background: A short-term protocol for evaluation of National Football League (NFL) athletes incurring concussion has yet to be fully defined and framed in the context of the short-term potential team and career longevity, financial risk, and performance. Purpose: To compare the short-term career outcomes for NFL players with concussions by analyzing the effect of concussions on (1) franchise release rate, (2) career length, (3) salary, and (4) performance. Study Design: Cohort study; Level of evidence, 3. Methods: NFL player transaction records and publicly available injury reports from August 2005 to January 2016 were analyzed. All players sustaining documented concussions were evaluated for a change to inactive or DNP (“did not participate”) status. A case-control design compared franchise release rates and remaining NFL career span. Career length was analyzed via survival analysis. Salary and performance differences were analyzed with publicly available contract data and a performance-scoring algorithm based on position/player level. Results: Of the 5894 eligible NFL players over the 11-year period, 307 sustained publicly reported concussions resulting in the DNP injury protocol. Analysis of the probability of remaining in the league demonstrated a statistically significantly shorter career length for the concussion group at 3 and 5 years after concussion. The year-over-year change in contract value for the concussion group resulted in a mean overall salary reduction of

Development of a rapidly deployable mobile medical unit for emergency disaster settings

300,000 ±

Evidence-Based Thresholds for the Volume-Value Relationship in Adolescent Idiopathic Scoliosis: Outcomes and Economies of Scale

1,300,000 per year (interquartile range, –

Outcomes of Cementless Total Knee Arthroplasty in Patients With Rheumatoid Arthritis

723,000 to

The Evidence Behind Peroxide in Orthopedic Surgery

450,000 per year). The performance score reduction for all offensive scoring players sustaining concussions was statistically significant. Conclusion: This retrospective study demonstrated that NFL players who sustain a concussion face a higher overall franchise release rate and shorter career span. Players who sustained concussions may incur significant salary reductions and perform worse after concussion. Short-term reductions in longevity, performance, and salary after concussion exist and deserve additional consideration.

Prevalence and Epidemiology of Injuries Among Elite Cyclists in the Tour de France

Abstract Background Mobile medical units are essential for rapid delivery of medical care in remote areas during crises. Baylor Global Innovation Center aimed to conceptualise, build, and deploy an Emergency Smart Pod (ESP)—a mobile medical unit customised for global emergencies—with a four-phase approach: human-centred design, development, user testing, and implementation. Methods An initial design was created based on the Ebola Grand Challenge Funding requirements granted by USAID in 2015. The design was then vetted using a 37-question survey via in-depth interviews with experts with field experience: logisticians, health-care workers, and Ebola Treatment Unit directors in the USA, Sierra Leone, Liberia, and Guinea. This design focused on addressing direct needs of end users by providing a rapidly deployable clinical solution with tablet-based wireless technologies, disinfectable materials, and appropriate storage for biohazard waste and medical supplies. The aluminium design of the unit optimised the lightweight capability, durability, and expandability. Manufacturers meeting these requirements were investigated for affordability, and technologies were developed for customised needs of infection control and emergency response. Feedback from field workers, NASA engineers, and physicians was continually evaluated throughout the building process. Findings A prototype equipped with smart applications optimised to protect health-care workers, improve patient care, and prevent disease transmission was built and tested. An ultraviolet C- heating, ventilation, and air conditioning system was implemented to kill 99·7% of pathogens. Medical record and wireless patient monitoring systems were developed for the high patient throughput in disaster situations. Remote video and push-to-talk systems were implemented to facilitate communication between the hot and cold zones. The ESP was built as an expandable aluminium-based box deployable via ships and trucks. A full simulation was initiated in Houston, TX, USA with simulated patients and health-care workers in full personal protective equipment. Improvements were made prior to shipping the unit to Monrovia, Liberia, for infectious disease care. The ESP was then successfully deployed in September, 2017, at the Eternal Love Winning Africa (ELWA) Hospital as a patient isolation unit. Interpretation Corresponding pharmacy and laboratory units are being developed as additions to the ESP. Similar validation will be used for these units for future deployment. Funding Vulcan Incs Paul G Allen Ebola Program USAID Bureau for Global Health—Center for Accelerating Innovation and Impact.

Fixed and Variable Relationship Models to Define the Volume-Value Relationship in Spinal Fusion Surgery: A Macroeconomic Analysis Using Evidence-Based Thresholds

OBJECTIVES Increased surgeon and hospital volume has been associated with improved patient outcomes and cost effectiveness for adolescent idiopathic scoliosis (AIS). However, no evidence-based thresholds that clarify the volume at which these strata occur exist. The objective of this study was to establish statistically meaningful thresholds that define high-volume surgeons and hospitals performing spinal fusion for AIS from those that are low volume with respect to length of stay (LOS) and cost. METHODS Using 3,224 patients undergoing spinal fusion for AIS from an administrative database, we created and applied four models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. We generated four sets of thresholds predictive of adverse outcomes, namely, increased cost and LOS, for both surgeon and hospital volume. RESULTS For both LOS and cost, surgeon volume produced the same strata with low volume identified as 0-5 annual surgeries and high as greater than 5. LOS and cost decreased significantly (p < .05) between volume strata. For hospital volume in terms of LOS, low volume was identified as 0-10 annual surgeries and high as greater than 10; in terms of cost, low volume was identified as 0-15 annual surgeries and high as greater than 15. LOS decreased significantly (p < .05) and cost was