The COVID-19 Pandemic and Centers of Medicaid and Medicare Services Regulatory Reform Impact on Total Hip Arthroplasty Metrics.

BACKGROUND: Shifts in demand, capacity, and site of service have impacted total hip arthroplasty (THA) volumes and revenues over the 2019-2021 time period. Moving THA off the inpatient-only (IPO) list and the COVID-19 pandemic has caused a shift in delivery away from inpatient services and a decrease in demand. METHODS: Medicare claims data were surveyed for the latest period available (April 1, 2020 to September 2020) and compared with a similar period in 2019 prior to THA removal from the IPO list and before the COVID-19 pandemic. Length of stay (LOS), admission status, site of service, discharge status, cost to CMS (Centers of Medicaid and Medicare Services), and racial disparities were analyzed. RESULTS: From 2019 to 2020, changes in primary THA metrics occurred (overall change in total joint arthroplasty [THA plus total knee arthroplasty metrics]): CMS THA volume decreased from 78,691 to 65,360, -16% (-22%); THA performed as an outpatient increased from 0% to 51% (141%); THA performed as same-day discharge increased from 3% to 12%, 325% (221%); overall LOS decreased from 1.91 to 1.46, -23% (-11%); inpatient LOS increased from 1.92 to 2.05, 7% (16%); outpatient LOS increased from 0.92 to 0.93, 1% (-12%); discharge home increased from 82% to 91%, 12.8% (11%); and CMS spending decreased from $1,033 million to $751 million, -27% (-27%). CONCLUSION: Medicare payments, LOS, discharge to facilities, and volume declined from 2019 to 2020 and were accelerated by IPO list changes and COVID-19 issues. Same-day discharge and hospital outpatient department cases also increased. THA metrics were not affected by race.

Randomised comparative effectiveness trial of Pulmonary Embolism Prevention after hiP and kneE Replacement (PEPPER): the PEPPER trial protocol.

INTRODUCTION: More than 1 million elective total hip and knee replacements are performed annually in the USA with 2% risk of clinical pulmonary embolism (PE), 0.1%-0.5% fatal PE, and over 1000 deaths. Antithrombotic prophylaxis is standard of care but evidence is limited and conflicting. We will compare effectiveness of three commonly used chemoprophylaxis agents to prevent all-cause mortality (ACM) and clinical venous thromboembolism (VTE) while avoiding bleeding complications. METHODS AND ANALYSIS: Pulmonary Embolism Prevention after HiP and KneE Replacement is a large randomised pragmatic comparative effectiveness trial with non-inferiority design and target enrolment of 20 000 patients comparing aspirin (81 mg two times a day), low-intensity warfarin (INR (International Normalized Ratio) target 1.7-2.2) and rivaroxaban (10 mg/day). The primary effectiveness outcome is aggregate of VTE and ACM, primary safety outcome is clinical bleeding complications, and patient-reported outcomes are determined at 1, 3 and 6 months. Primary data analysis is per protocol, as preferred for non-inferiority trials, with secondary analyses adherent to intention-to-treat principles. All non-fatal outcomes are captured from patient and clinical reports with independent blinded adjudication. Study design and oversight are by a multidisciplinary stakeholder team including a 10-patient advisory board. ETHICS AND DISSEMINATION: The Institutional Review Board of the Medical University of South Carolina provides central regulatory oversight. Patients aged 21 or older undergoing primary or revision hip or knee replacement are block randomised by site and procedure; those on chronic anticoagulation are excluded. Recruitment commenced at 30 North American centres in December 2016. Enrolment currently exceeds 13 500 patients, representing 33% of those eligible at participating sites, and is projected to conclude in July 2024; COVID-19 may force an extension. Results will inform antithrombotic choice by patients and other stakeholders for various risk cohorts, and will be disseminated through academic publications, meeting presentations and communications to advocacy groups and patient participants. TRIAL REGISTRATION: NCT02810704.

The Changing Economic Value and Leverage of Arthroplasty Surgeons.

Moving THA off of the Inpatient Only (IPO) List for Center of Medicaid and Medicare Services (CMS) beneficiaries and the COVID-19 pandemic has caused a shift in delivery away from inpatient services and a decrease in demand. Medicare payments dramatically declined from 2019 to 2020. LOS decreases and shift to outpatient designations were accelerated by IPO list changes and COVID-19 issues. The percentage of SDD cases also increased. Other metrics favorable to decreased spending by CMS were increased discharge to home and decreased volume. These changes have a profound impact on surgeon-hospital relationships and surgeon compensation.

Worsening Arthroplasty Utilization With Widening Racial Variance During the COVID-19 Pandemic.

BACKGROUND: Elective arthroplasty surgery in the United States came to a near-complete halt in the spring of 2019 as a response to the COVID-19 pandemic. Racial disparity has been a long-term concern in healthcare with increased focus during the pandemic. The purpose of this study is to evaluate the effects of COVID-19 and race on arthroplasty utilization trends during the pandemic. METHODS: We used 2019 and 2020 Center for Medicare and Medicaid Service fee-for-service claims data to compare arthroplasty volumes prior to and during the COVID-19 pandemic. We compared overall arthroplasty utilization rates between 2019 and 2020 and then sought to determine the effect of race and COVID-19, both independently and combined. RESULTS: There was a decrease in primary total knee arthroplasty (-28%), primary total hip arthroplasty (-14%), primary total hip arthroplasty for fracture (-2%), and revision arthroplasty (-14%) utilization between 2019 and 2020. The highest decrease in overall arthroplasty utilization was in the Hispanic population (34% decrease vs 19% decrease in the White population). We found that a non-White patient was 39.9% (P < .001) less likely to receive a total joint arthroplasty prior to COVID-19. The COVID-19 pandemic further exacerbated the pre-existing racial differences in arthroplasty utilization by decreasing the probability of receiving a total joint arthroplasty for non-White patient by another 12.9% (P < .001). CONCLUSION: We found an overall decreased utilization rate of arthroplasty during the COVID-19 pandemic with further decrease noted in all non-White populations. This raises significant concern for worsening racial disparity in arthroplasty caused by the ongoing pandemic.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons.

BACKGROUND: A survey was conducted at the 2021 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to evaluate current practice management strategies among AAHKS members. METHODS: An application was used by AAHKS members to answer both multiple-choice and yes or no questions. Specific questions were asked regarding the impact of COVID-19 pandemic on practice patterns. RESULTS: There was a dramatic acceleration in same day total joint arthroplasty with 85% of AAHKS members performing same day total joint arthroplasty. More AAHKS members remain in private practice (46%) than other practice types, whereas fee for service (34%) and relative value units (26%) are the major form of compensation. At the present time, 93% of practices are experiencing staffing shortages, and these shortages are having an impact on surgical volume. CONCLUSION: This survey elucidates the current practice patterns of AAHKS members. The pandemic has had a significant impact on some aspects of practice activity. Future surveys need to monitor changes in practice patterns over time.

American Association of Hip and Knee Surgeons Advocacy Efforts in Response to the SARS-CoV-2 Pandemic.

As soon as it became clear that our economy was going to be paralyzed by the SARS-CoV-2 pandemic, the American Association of Hip and Knee Surgeons leadership acted swiftly to ensure that our members were going to be eligible for the anticipated federal economic stimulus. The cessation of elective surgery, enacted in mid-March and necessary to stop the spread of the SARS-CoV-2 virus, would surely challenge the solvency of many of our members' practices. Although our advocacy efforts discussed further have helped, clearly more relief is needed. Fortunately, our mitigation efforts have led to a "flattening of the curve" and discussions have begun on when, where, and how to safely start elective surgery again.

Economic Recovery After the COVID-19 Pandemic: Resuming Elective Orthopedic Surgery and Total Joint Arthroplasty.

BACKGROUND: The economic effects of the COVID-19 crisis are not like anything the U.S. health care system has ever experienced. METHODS: As we begin to emerge from the peak of the COVID-19 pandemic, we need to plan the sustainable resumption of elective procedures. We must first ensure the safety of our patients and surgical staff. It must be a priority to monitor the availability of supplies for the continued care of patients suffering from COVID-19. As we resume elective orthopedic surgery and total joint arthroplasty, we must begin to reduce expenses by renegotiating vendor contracts, use ambulatory surgery centers and hospital outpatient departments in a safe and effective manner, adhere to strict evidence-based and COVID-19-adjusted practices, and incorporate telemedicine and other technology platforms when feasible for health care systems and orthopedic groups to survive economically. RESULTS: The return to normalcy will be slow and may be different than what we are accustomed to, but we must work together to plan a transition to a more sustainable health care reality which accommodates a COVID-19 world. CONCLUSION: Our goal should be using these lessons to achieve a healthy and successful 2021 fiscal year.