Outpatient Versus Rapid Recovery Inpatient Knee Arthroplasty: Comparison of Matched Cohorts.

Increased focus on reducing the cost of total knee arthroplasty (TKA) has driven greater interest in performing the procedure in an outpatient setting. This study used exact matching to compare clinical and economic outcomes following TKA in an outpatient vs rapid recovery inpatient setting. This study used a nationally representative commercial database. Patients were grouped into 2 cohorts: same-day outpatient TKA (surgery center or hospital outpatient) or short-stay inpatient TKA ("rapid recovery"; length of stay 1 day or less). Only patients discharged home under self-care or with health care were included. Exact 1:1 matching was performed on clinical and demographic characteristics to control for potential case-selection bias by choice of care setting. Prior to matching, 969 outpatients and 8101 rapid recovery inpatients met selection criteria. The outpatient cohort was younger (median age, 58 vs 61 years), predominantly female (56% vs 51%), and less comorbid (Charlson Comorbidity Index score of 0: 84.2% vs 74.0%) vs the rapid recovery cohort. Post-match, 863 patients were available in each cohort. The outpatient cohort exhibited a significantly lower incidence of opiate use (80.4% vs 90.7%; P<.001) and minor complications (2.8% vs 5.8%; P=.002). Incidence of major complications (5.2% vs 6.7%, P=.173) and 90-day readmissions (5.1% vs 7.3%, P=.064) were equivalent. The outpatient median 90-day episode payment was $6824 lower (22%) per patient ($24,749 vs $31,573, respectively; P<.001). This study suggests that among carefully selected patients undergoing outpatient TKA, outcomes are equivalent, if not improved, at a lower payor cost compared with a rapid recovery inpatient setting. [Orthopedics. 2020; 43(1):36-41.].

Blood Transfusion Trends in Primary and Revision Total Joint Arthroplasty: Recent Declines Are Not Shared Equally.

INTRODUCTION: This study examined whether recent nationwide declines in the incidence of transfusion following total joint arthroplasty were equal across inpatient facilities. METHODS: This analysis used the Premier database (2010 to 2015). Cohorts of primary total hip or knee arthroplasty (THA or TKA) and revision THA or TKA were defined. RESULTS: Among 1,013,024 patients who met selection criteria, the overall incidence of transfusion declined from 2010 through 2015 (primary THA: 22.1% to 7.1%; primary TKA: 18.1% to 3.2%; revision THA: 30.6% to 18.5%; and revision TKA: 19.8% to 9.8%; all P < 0.001). However, patients older than 65 years were associated with lower odds of transfusion relative to those younger than 65 years (P < 0.05 for three of four cohorts); smaller hospitals were associated with higher odds versus large hospitals (P < 0.05 all cohorts), and academic hospitals were associated with higher odds of transfusion versus community facilities (P < 0.05 for three of four cohorts). DISCUSSION: During this study period, a meaningful proportion of total joint arthroplasty procedures were performed at facilities with the most room to improve. Decreases in transfusion rates were dependent on specific hospital characteristics; these results may help direct targeted improvement initiatives. LEVEL OF EVIDENCE: Level III.

Skilled Nursing Facility Star Rating, Patient Outcomes, and Readmission Risk After Total Joint Arthroplasty.

BACKGROUND: This study examined the correlation between publicly reported indicators of skilled nursing facility (SNF) quality and clinical outcomes after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: This retrospective analysis used Medicare claims from the Centers for Medicare and Medicaid Services 100% Standard Analytic File (2014-2015) that were linked to SNF quality star ratings from the Centers for Medicare and Medicaid Services Nursing Home Compare database. Overall SNF rating and subcomponents of the rating were evaluated for correlation to 30-day and 90-day risk of readmission. Ratings were based upon a 5-star rating system (1 representing the lowest quality). Cox proportional hazards regressions controlled for age, race, census division, hospital location, comorbidities, and SNF length of stay. RESULTS: A total of 9418 SNFs, 58,064 TKA patients, and 26,837 THA patients met criteria. As SNF overall star rating increased from 1 to 5, incidence of all-cause 30-day readmission decreased from 6.4% to 5.0% for TKA (relative reduction [RR] 22%; P < .001) and from 9.1% to 6.2% for THA (RR 32%; P < .001). As nurse staffing rating increased, incidence of all-cause readmission decreased from 6.8% to 4.7% for the TKA cohort (30.9% RR; P < .001), and from 7.7% to 6.0% for the THA cohort (22.1% RR; P = .003). Regression analysis demonstrated that a higher star rating was associated with decreased risk of readmission (both cohorts P < .05). CONCLUSIONS: For patients undergoing TKA or THA, the overall SNF star rating, nurse staffing ratios, and physical therapy intensity were significantly correlated with risk of readmission within 30 days of SNF admission.

The Payer and Patient Cost Burden of Open Breast Conserving Procedures Following Percutaneous Breast Biopsy.

OBJECTIVES: Percutaneous core-needle biopsy (PCNB) is the standard of care to biopsy and diagnose suspicious breast lesions. Dependent on histology, many patients require additional open procedures for definitive diagnosis and excision. This study estimated the payer and patient out-of-pocket (OOP) costs, and complication risk, among those requiring at least 1 open procedure following PCNB. METHODS: This retrospective study used the Truven Commercial database (2009-2014). Women who underwent PCNB, with continuous insurance, and no history of cancer, chemotherapy, radiation, or breast surgery in the prior year were included. Open procedures were defined as open biopsy or lumpectomy. Study follow-up ended at chemotherapy, radiation, mastectomy, or 90 days-whichever occurred first. RESULTS: In total, 143 771 patients (mean age 48) met selection criteria; 85.1% underwent isolated PCNB, 12.4% one open procedure, and 2.5% re-excision. Incidence of complications was significantly lower among those with PCNB alone (9.2%) vs 1 open procedure (15.6%) or re-excision (25.3%, P < .001). Mean incremental commercial payments were US $13 190 greater among patients with 1 open procedure vs PCNB alone (US $17 125 vs US $3935, P < .001), and US $4767 greater with re-excision (US $21 892) relative to 1 procedure. Mean patient OOP cost was US $858 greater for 1 open procedure vs PCNB alone (US $1527 vs US $669), and US $247 greater for re-excision vs 1 procedure. CONCLUSIONS: A meaningful proportion of patients underwent open procedure(s) following PCNB which was associated with increased complication risk and costs to both the payer and the patient. These results suggest a need for technologies to reduce the proportion of cases requiring open surgery and, in some cases, re-excision.