Time Waits For No One—Aging Increases Costs
The cost of medical care in the United States has been shown to rise with advancing patient age, and total joint arthroplasty (TJA) is a prime example of this unsurprising phenomenon. In attempts to curtail costs and reduce variability, Medicare and other payers have introduced alternative payment models (APMs), such as the Bundled Payments for Care Improvement (BPCI) initiative. In this model’s application to TJA, when participating institutions keep the cost of the “episode” below a risk-adjusted target price, they accrue the savings as a profit, but they sustain a financial penalty if the episode costs more than the target price.
Multiple studies have suggested that APMs can negatively affect the fiscal health of institutions that care for many high-risk patients. Although increasing age has been associated with higher-cost episodes of care, age is not one of the factors that the BPCI model accounts for. Consequently, concerns have been raised that providers may practice “cost discrimination” against very old patients.
In the October 7, 2020 issue of The Journal, Petersen et al. examine how an aging population has affected a New York City orthopaedic center in terms of the BPCI model applied to TJA. The authors analyzed the relationship between patient age and cost of care among 1,662 patients who underwent primary total hip and knee arthroplasty over a 3-year period under BPCI. They then used a modeling tool to predict shifting age demographics for their local area out to the year 2040.
Petersen et al. found that under BPCI, their institution sustained a nearly $2,000-per-case loss for TJA care episodes among patients 85 to 99 years of age. Currently this loss is offset by profits realized by performing TJAs in younger patients. However, predictive modeling identified an inflection point of 2030, after which a relative increase in older patients and a decrease in younger patients will yield an overall net decrease in profits for primary TJA.
Because no one, including orthopaedic surgeons, can turn back the clock on aging, health care stakeholders must find ways either to adjust downward the cost of care for the elderly (seemingly difficult without adversely affecting outcomes) or adjust reimbursement models to account for the increased costs associated with aging. I agree with the conclusion of Petersen et al.: “The BPCI initiative and [other] novel APMs should consider age as a modifier for reimbursement to incentivize care for the more vulnerable and costly age groups in the future.”
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Cost-Effectiveness of PRP for Knee OA Questioned
The cost-effectiveness analysis of platelet-rich plasma (PRP) for knee osteoarthritis by Rajan et al. in the September 16, 2020 issue of JBJS is accompanied by 105 references. That’s just one indication of the level of interest in this anti-inflammatory and pro-angiogenic orthobiologic. Current literature suggests that PRP is safe, but its clinical efficacy in musculoskeletal conditions has been hotly debated in the orthopaedic community.
Rajan et al. applied Markov decision analysis to a clinical scenario in which a 55-year-old patient with Kellgren-Lawrence grade-II or III knee osteoarthritis (OA) undergoes either a series of 3 PRP injections and a 1-year delay to total knee arthroplasty (TKA), or TKA from the outset. Their primary outcome measures were total costs and quality-adjusted life years (QALYs), organized into incremental cost-effectiveness ratios (ICERs). In Markov analyses, if one treatment costs less and produces more QALYs than a comparative treatment, it is considered to be the “dominant” approach.
The authors found that, from a health-care payer perspective, PRP (at an estimated cost of $728 per injection in 2018 US dollars) was not cost-effective if it yielded only a 1-year delay of TKA. However, from a societal perspective (which considered both lost productivity and the need for unpaid caregiving associated with TKA surgery), PRP was cheaper over a lifetime because it delayed direct and indirect costs associated with TKA. The ICER for TKA at the outset was $4,175 per QALY, which is well below the predetermined willingness-to-pay threshold of $50,000. The authors emphasize that this favorable ICER reflects the improved quality of life after TKA compared with published results of PRP injections for knee OA.
Rajan et al. do specify a clinical scenario in which PRP may have a cost-effectiveness advantage over TKA: “…in a higher-risk patient population in whom the perioperative complication rates, TKA revision rate, or postoperative functional outcomes are projected to be worse.”
Preop X-Rays Don’t Predict TKA Patient-Reported Outcomes
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from David Vizurraga, MD in response to a recent study in JBJS Open Access.
Whoever coined the phrase, “a picture is worth a thousand words” never treated a patient with knee osteoarthritis (OA). While knee OA is one of the most common conditions encountered in orthopaedic practice and its diagnosis and treatment are fairly straightforward, predicting the outcomes of total knee arthroplasty (TKA)—the definitive treatment for most cases of end-stage knee OA—can be challenging. The severity of OA on radiographs has long been debated as a tool to aid surgeons in predicting post-TKA outcomes and framing expectations for patients. In general, we tend to say, “The worse the x-ray, the better the patient-reported outcome,” and conversely, “The better the x-ray, the worse the patient-reported outcome.”
Lange et al. investigated this assumption in a study published in JBJS Open Access on July 9, 2020. The authors leveraged data from a 2-arm, randomized controlled trial that evaluated the role of “motivational interviewing” in enhancing rehabilitation following TKA. In their cohort analysis, Lange et al. compared pre- and postoperative WOMAC pain scores and KOOS activities-of-daily-living (ADL) scores with preoperative radiographic severity of knee OA, as measured by the Osteoarthritis Research Society International (OARSI) Atlas score. Among the 240 patients who had 2-year outcome measures and imaging available, the median preoperative OARSI score was 10 (on a scale of 0 to 18), and the authors defined “milder OA” as an OARSI score of <10 and “more severe OA” as a score of ≥10.
The researchers found a cohort-wide postoperative improvement in WOMAC pain and KOOS ADL scores of ~30 points, but they did not find any significant or clinically important differences in pain and function scores between patients with “milder OA” and “more severe OA.” The authors were also unable to demonstrate any correlation between radiographic severity and pain and function scores preoperatively.
Additionally, Lange et al. looked for associations between the WOMAC and KOOS improvements and 4 four other radiographic assessments of knee OA severity (Kellgren-Lawrence grade, compartment-specific OARSI score, compartment-specific joint-space-narrowing score, and 4-level OARSI score). Again, they failed to observe any clinically important postoperative differences in pain or function between the subjects with radiographically milder or more severe OA.
These findings provide further evidence that radiographs should represent only one piece in the puzzle of diagnosis and treatment planning for our patients with knee OA. To me, it’s worth noting that the study capitalized on data from a trial investigating motivational interviewing, which aims to improve outcomes by empowering patients—yet in the multivariable analysis that adjusted for several confounders, use of motivational interviewing was not among them. Still, the many aspects of outcome prediction following knee replacement are most definitely worthy and in need of continued investigation.
David Vizurraga, MD is a San Antonio-based orthopaedic surgeon specializing in adult hip and knee reconstruction and a member of the JBJS Social Media Advisory Board.
September 2020 Article Exchange with JOSPT
For the last 6 years, JBJS has participated in an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of September 2020, JBJS and OrthoBuzz readers will have open access to the JOSPT systematic review titled “Meniscus or Cartilage Injury at the Time of Anterior Cruciate Ligament Tear Is Associated with Worse Prognosis for Patient-Reported Outcome 2 to 10 Years after Injury.”
The authors of this systematic review conclude that “patients, physical therapists, orthopaedic surgeons, and athletic trainers [should] be aware that concomitant meniscus or cartilage injuries may lead to worse knee function 2 to 10 years after ACL reconstruction.”
Validity of Non-English PROMs to Assess TKA
Patient-reported outcome measures (PROMs) have become increasingly important tools in the 30 years since the orthopaedic community began embracing the movement toward the “patient perspective.” Clinical findings such as range of motion and imaging results remain important, but we have come to understand that pain and function–as reported by the patient–are the most crucial data points. And we are not alone. Insurance companies, registries, scholarly publications, and research review panels now often require PROMs as part of their core evaluations.
But not all PROMs are created equal. For clinicians to trust the output from these instruments, validation of the measures is required. This entails reliability testing and assessment of face, construct, and criterion validity. Furthermore, translating PROMs validated in English into other languages involves not only linguistic translation, but also cultural components in order to capture the full patient perspective.
In the August 5, 2020 issue of The Journal, Bin Sheeha et al. report their work in evaluating the responsiveness, reliability, and validity of the Arabic-language version of the Oxford Knee Score (OKS-Ar). After painstaking statistical analysis of OKS-Ar questionnaires completed by 100 Arabic-speaking patients (80 of whom were female) before and after total knee arthroplasty (TKA), the authors concluded that the OKS-Ar is a valid, sensitive, and easy-to-use instrument to assess pain and function in TKA-treated individuals whose main language is Arabic.
To be truthful, this is not very glamorous research to conduct or very exciting to read about. However, it is absolutely fundamental to ensuring the validity of multicenter, international trials and registry studies. In essence, Bin Sheeha et al. have dug a conduit that facilitates the flow of reliable data and that will help improve future patient care worldwide. As such, it deserves our attention, understanding, and appreciation.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
What’s New in Musculoskeletal Infection 2020
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz specialty-update summaries.
This month, Thomas K. Fehring, MD, co-author of the July 15, 2020 “What’s New in Musculoskeletal Infection,” selected the five most clinically compelling findings—all focused on periprosthetic joint infection (PJI)—from among the more than 80 noteworthy studies summarized in the article.
PJI Prevention
–A retrospective case-control study1 found that patients who received an allogeneic blood transfusion during or after knee or hip replacement had a higher risk of PJI than those who were not transfused.
PJI Diagnosis
–A retrospective review2 found that using inflammatory markers to diagnose PJI in immunosuppressed joint-replacement patients is not suitable and that newly described thresholds for synovial cell count and differential have better operative characteristics.
Treating PJI
–A retrospective review3 of a 2-stage debridement protocol with component retention in 83 joint-replacement patients showed an 86.7% success rate of infection control at an average follow-up of 41 months.
–A single-center study4 of perioperative antibiotic selection for patients undergoing total joint arthroplasty found that the risk of PJI was 32% lower among those who received cefazolin compared with those who received other antimicrobial agents. The findings emphasize the importance of preoperative allergy testing in patients with stated beta-lactam allergies.
–A review of regional and state antibiograms5 showed that 75% of methicillin-sensitive S. aureus (MSSA) isolates and 60% of both methicillin-resistant S. aureus (MRSA) and coagulase-negative Staphylococcus isolates were susceptible to clindamycin, whereas 99% of all isolates were susceptible to vancomycin.
References
- Taneja A, El-Bakoury A, Khong H, Railton P, Sharma R, Johnston KD, Puloski S, Smith C, Powell J. Association between allogeneic blood transfusion and wound infection after total hip or knee arthroplasty: a retrospective case-control study. J Bone Jt Infect. 2019 Apr 20;4(2):99-105.
- Lazarides AL, Vovos TJ, Reddy GB, Kildow BJ, Wellman SS, Jiranek WA, Seyler TM. Traditional laboratory markers hold low diagnostic utility for immunosuppressed patients with periprosthetic joint infections. J Arthroplasty.2019 Jul;34(7):1441-5. Epub 2019 Mar 12.
- Chung AS, Niesen MC, Graber TJ, Schwartz AJ, Beauchamp CP, Clarke HD, Spangehl MJ. Two-stage debridement with prosthesis retention for acute periprosthetic joint infections. J Arthroplasty.2019 Jun;34(6):1207-13. Epub 2019 Feb 16.
- Wyles CC, Hevesi M, Osmon DR, Park MA, Habermann EB, Lewallen DG, Berry DJ, Sierra RJ. 2019 John Charnley Award: Increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin: the value of allergy testing for antibiotic prophylaxis. Bone Joint J.2019 Jun;101-B(6_Supple_B):9-15.
- Nodzo SR, Boyle KK, Frisch NB. Nationwide organism susceptibility patterns to common preoperative prophylactic antibiotics: what are we covering? J Arthroplasty.2019 Jul;34(7S):S302-6. Epub 2019 Jan 17.
Predictors of Prolonged Analgesic Use after Joint Replacement
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Eric Secrist, MD in response to a recent study in Arthritis Research & Therapy.
There has been a proliferation of research regarding postoperative opioid usage after joint arthroplasty due to the widespread opioid epidemic. But Rajamäki and colleagues from Tampere University in Finland took the unique approach of also analyzing acetaminophen and NSAID usage in addition to opioids. The authors used robust data from Finland’s nationwide Drug Prescription Register, which contains reliable information on all medications dispensed from pharmacies, including over-the-counter drugs.
After excluding patients who underwent revision surgery or had their knee or hip replaced for a diagnosis other than osteoarthritis, the authors analyzed 6,238 hip replacements in 5,657 patients and 7,501 knee replacements in 6,791 patients, all performed between 2002 and 2013. The mean patient age was 68.7 years and the mean BMI was 29.
One year postoperatively, 26.1% of patients were still filling prescriptions for one or more analgesics, including NSAIDs (15.5%), acetaminophen (10.1%), and opioids (6.7%). Obesity and preoperative analgesic use were the strongest predictors of prolonged analgesic medication usage 1 year following total joint arthroplasty. Other predictors of ongoing analgesic usage included older age, female gender, and higher number of comorbidities. Patients who underwent knee replacement used the 3 analgesics more often than those who underwent hip replacement.
This study had all of the limitations inherent in retrospective database analyses. Additionally, it was not possible for the authors to determine whether patients took analgesic medications for postoperative knee or hip pain or for pain elsewhere in their body. Finally, the authors utilized antidepressant reimbursement data as a surrogate marker for depression and other medications as a surrogate for a Charlson Comorbidity Index.
Figure 2 from this study (shown below) reveals 2 important findings. First, total joint arthroplasty resulted in a significant decrease in the proportion of patients taking an analgesic medication, regardless of BMI. Second, patients in lower BMI categories were less likely to use analgesics both preoperatively and postoperatively.
The findings from this study may be most useful during preoperative counseling for obese patients, who often present with severe joint pain but are frequently told they need to delay surgery to lose weight and improve their complication-risk profile. Based on this study, those patients can be counseled that losing weight will not only decrease their complication risk, but also decrease their reliance on medications for the pain that led them to seek surgery in the first place.
Eric Secrist, MD is a fourth-year orthopaedic resident at Atrium Health in Charlotte, North Carolina.
July 2020 Article Exchange with JOSPT
For the last 6 years, JBJS has participated in an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of July 2020, JBJS and OrthoBuzz readers will have open access to the JOSPT systematic review and meta-analysis titled “Effectiveness of Weight-Loss Interventions for Reducing Pain and Disability in People with Common Musculoskeletal Disorders.”
The authors found low-credibility evidence that behavioral weight-loss interventions produced small to moderate improvements in pain intensity and disability in people with hip or knee osteoarthritis. They also found moderate-credibility evidence that combined diet and exercise weight-loss strategies improved pain intensity and disability compared to diet-only interventions for knee osteoarthritis.
UKA: Alignment and Overhang Matter
(Reproduced, with permission, from Orthop Traumatol Surg Res. 2016 Apr;102[2]:183-7. Copyright © 2016 Elsevier Masson SAS. All rights reserved.)
These operations were performed by a group of fairly experienced surgeons who averaged >14 UKAs per year, although a commonly used threshold for a “high-volume” UKA surgeon is >15 procedures per year. The cumulative revision rate of 14.2% over 8.7 years, the 5-year Kaplan-Meier survival rate of 88%, and the 10-year survival rate of 70% found by Kazarian et al. are disturbing. Using revision as an endpoint may be problematic because some surgeons are quick to revise a UKA when the radiographic evaluation of component placement is not perfect. Still, this study demonstrates that radiographically determined alignment and overhang “outliers” and “far outliers” had a significantly increased risk of implant failure, compared with patients with good alignment and overhang.
This study did not include UKAs that used computer-assisted methods, but it seems safe to conclude that computer-assisted component placement would be more reliable than “eyeballing,” especially among surgeons with less-experienced eyes. Based on this and other recent studies, I think a controlled trial comparing the functional outcomes and revision rates of UKAs performed with and without computer assistance is warranted.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Editor’s Note: Click here to read the JBJS Clinical Summary on Unicompartmental Knee Arthroplasty.
TKA Cost Efficiency Is Improving, But We Can Do Better
Wide variability in the cost and quality of health care in the US has led some to describe our system as “uniquely inefficient.” Consequently, we continue to study variability intensely, especially in the realm of joint arthroplasty. In the June 3, 2020 issue of The Journal, Schilling et al. elegantly analyze the variations in 90-day episode payments made by Medicare Part A for total knee arthroplasty (TKA) from 2014 to 2016. In so doing, they provide a snapshot of hospital cost performance and, just as importantly, they offer a methodology by which to measure future hospital-level cost performance with this very popular surgery.
The authors reviewed >700,000 TKAs in the Medicare population at a time prior to the full implementation of the Comprehensive Care for Joint Replacement (CJR) model, and they ranked >3,200 hospitals within 9 US regions to determine cost performance. Schilling et al. found that during those 3 years, the mean Medicare episode payment for TKA decreased significantly, due almost entirely to a >$1,500 per-case decrease in post-acute care payments, which included lower costs for skilled nursing facilities and inpatient rehabilitation. Also decreasing during that same period were length of hospital stay and 90-day readmission rates.
These findings highlight the improvements in care and cost efficiency that were occurring even before implementation of the CJR. In a Commentary on this study, Susan Odum, PhD suggests that “the improved value of TKA illustrated by Schilling et al. includes the successful impacts of the BPCI [Bundled Payments for Care Improvement] program,” an alternative payment model that Medicare rolled out beginning in 2013.
On the other hand, the authors also reveal a persistently high degree of variability in episode payments and resource utilization both across and within geographic regions. This strongly suggests the possibility of further improvement. Regardless of which, if any, alternative payment model we participate in, everyone in the orthopaedic community should think about how to become more efficient in our delivery of musculoskeletal care. And this study provides a conceptual framework and benchmarks for identifying where the room for improvement is.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
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