The role of bladder catheterization in total knee arthroplasty.

The use of a urinary bladder catheter in the perioperative period for patients undergoing total knee arthroplasty is controversial. In the current study, two bladder management protocols were studied. One group of patients had an indwelling catheter inserted into the bladder before total knee arthroplasty. The other group of patients was observed and treated for urinary retention as necessary. From 1993 to 1998, 652 patients undergoing primary, unilateral total knee arthroplasty were randomized by surgeon into two groups: one group underwent preoperative insertion of an indwelling bladder catheter (306 patients), and one group (346 patients) had a catheter inserted postoperatively as necessary. Sixty-six percent (229 of 346) of these patients required catheterization (203 had indwelling catheters and 26 had intermittent straight catheters). A urinary tract infection developed in five patients (1.6%) in whom a catheter was inserted preoperatively. A urinary tract infection developed in six patients (1.7%) in whom a catheter was inserted if necessary. Five of these urinary tract infections developed in patients with delayed indwelling bladder catheters. A urinary tract infection did not develop in any patient in whom a straight catheter was inserted. There was no significant difference in the length of stay in the hospital between the two groups. The group in whom a catheter always was inserted generated $491 greater cost for total knee arthroplasty than patients in whom a catheter was inserted if necessary.

Single Price/Case Price Purchasing in orthopaedic surgery: experience at the Lahey Clinic.

BACKGROUND: Hospital revenues for orthopaedic operations are not keeping pace with inflation or with rising hospital expenses. In an attempt to reduce the hospital cost of orthopaedic operations by reducing the cost of operating-room supplies, we developed a Single Price/Case Price Purchasing Program for implants used in total hip arthroplasty, total knee arthroplasty, and total shoulder arthroplasty as well as for arthroscopic shavers and burrs, interference screws, and bone-suture anchors. METHODS: The Lahey Clinic asked orthopaedic vendors to supply all instruments, implants, and disposable items related to these selected products for one single price per unit or case. For example, a single price for total hip arthroplasty implants included instruments, acetabular cups, acetabular liners, acetabular screws, femoral stems, femoral heads, and stem centralizers, if required. The hospital implemented the Single Price/ Case Price Purchasing Program with a competitive-bid request for proposal. Surgeons evaluated the responses to the bidding process, and they made final decisions on product selection. RESULTS: The Single Price/Case Price Purchasing Program at the Lahey Clinic was successful in reducing the cost of orthopaedic implants and supplies. In the present article, we could not disclose the specific prices that we agreed to pay our vendors. The specific cost reductions were 32 percent for hip implants with a change of vendor, 23 percent for knee implants without a change of vendor, 25 percent for shoulder implants with a change of vendor, 45 percent for arthroscopic shavers and burrs without a change of vendor, 45 percent for interference screws without a change of vendor, and 23 percent for bone-suture anchors without a change of vendor. CONCLUSIONS: The Single Price/Case Price Purchasing Program at the Lahey Clinic allowed the hospital to reduce its cost of orthopaedic operations by lowering the cost of operating-room supplies. This cost reduction is important in a health-care economy in which hospital revenues per unit of service or care are decreasing.

Knee implant standardization: an implant selection and cost reduction program.

The largest single unit cost in the hospital cost for total knee arthroplasty (TKA) is the cost of knee implants. We developed a knee implant standardization program to provide guidelines for knee implant selection and to reduce the cost of knee implants for hospitals. Patients are assigned to demand categories based on five criteria: age, weight, expected activity, general health, and bone stock. Implants are assigned to demand categories based on an implant's projected capacity to handle the patient's projected demand. The program was applied retrospectively to 127 knee replacement operations performed on 93 patients during 1992. If this program had been in place, 8.4% of what was actually spent on knee implants for these 127 patients would have been saved. If the most expensive implants allowed in each demand category had actually been used, the program would have saved our hospital 12.8% of the cost of knee implants for these patients. Potential savings were noted in higher demand categories I and II by reducing the use of expensive cementless, porous-coated implants. The greatest potential savings were noted in lower demand categories III and IV: 11% savings could have been realized in demand category III, and 27% savings could have been achieved in the cost of knee implants in demand category IV. Potential savings would have been realized in these lower demand categories because of the recommended use of an all-polyethylene tibial component in 38 of 92 patients. This knee implant standardization program has the potential to assist surgeons in selecting knee implants and reduce the cost of knee implants without compromising outcome following TKA.

Impact of a clinical pathway and implant standardization on total hip arthroplasty: a clinical and economic study of short-term patient outcome.

This study evaluates the impact of a clinical pathway (CP) and a hip implant standardization program (HISP) on the quality and cost of total hip arthroplasty (THA). Two hundred six unilateral THA operations for osteoarthritis were evaluated: 89 operations were performed in 1991 without a CP or HISP (4-year follow-up period); 117 operations were performed in 1993 with a CP and HISP (2-year follow-up period). All patients had good clinical results and excellent outcomes with short-term follow-up evaluation. No differences were seen between groups in terms of patient ratings of outcome and satisfaction or in terms of complication rates in the hospital. Implementation of a CP and HISP did not adversely affect the short-term outcome of THA but did reduce hospital length of stay and hospital cost for THA.

Implant standardization for total hip arthroplasty. An implant selection and a cost reduction program.

Total hip arthroplasty (THA) has been targeted by the United States federal government for cost control because of its high cost and rising incidence in the aging population. The hospital cost for THA during the 1980s was controlled by utilization review and a reduction in the volume of services delivered for each THA. The single largest increase in the cost of THA during the 1980s was the cost of hip implants. The Lahey Clinic Hip Implant Standardization Program was developed to provide objective guidelines for hip implant selection. These guidelines are based on the demands a patients is expected to place on his or her hip prosthesis. Because not every patient requires an expensive high-demand hip prosthesis, the standardization program also has the potential to reduce the hospital cost for hip implants without compromising patient care. Patients are assigned to four demand categories based on five objective criteria: age, weight, expected activity, general health, and bone stock. Selection of the prosthesis in each of the four demand categories is intended to match the implant's capacity with expected patient demand. The standardization program was retrospectively applied to 103 THAs performed during 1991. Analysis of variance demonstrated that patient variables and demand categories were statistically significant groupings. The cost of hip implants would have been reduced by 25.7% with the Lahey Clinic Hip Implant Standardization Program. A prospective outcome study is required to determine the long-term validity of this standardization program.