Introduction. Hip fractures are a common pathology treated by Orthopaedic surgeons. The Comprehensive Care for Joint Replacement (CJR) model utilizes risk stratification to set target prices for these patients undergoing hemiarthroplasty or total hip arthroplasty (THA). We hypothesized that sub-specialty arthroplasty surgeons would be able to treat patients at a lower cost compared to surgeons of other specialties during cases performed while on call. Methods. Patients with hemiarthroplasty or THA for hip fractures were retrospectively collected from June, 2013, to May, 2017, from a single tertiary referral center. Demographic information and outcomes based on length of stay (LOS), net payment, and target payment were collected. Patients were then stratified by surgeon subspecialty (arthroplasty trained vs. other specialty). Univariable and multivariable analysis for payment based on treating surgeon was then performed. Results. 197 hip fracture patients were included through the collection period. 40 patients were treated by arthroplasty surgeons and 157 patients were not. There was no difference in LOS, however, when treated by arthroplasty trained surgeons, they were significantly more likely to have a lower net payment (32,507 vs. 42,518; p=0.001) with cost of care below the target payment (80.0% vs 51.6%; p=0.001), partially stemming from decreased discharges to skilled nursing facilities (p=0.008). In multivariable regression controlling for age, sex, BMI, ASA score, and procedure, arthroplasty surgeons were more likely to perform under the target price, which approached statistical significance (OR 2.177; 95% CI 0.866–5.474; p=0.098). Discussion and Conclusion. Hip fracture patients are commonly treated by on-call surgeons given the need to expedite their care. However, given the bundled payment model implemented by CJR, there must be special consideration to fracture stratification, implant selection, and surgeon experience. If feasible, our data suggests that an arthroplasty surgeon may contribute to decreased cost of care; a larger multicenter study is required

Waiting time to access medical care in Canada is 20% more than the international average. Delay in instituting care in trauma patients has been shown to correlate with higher complication rates and an increase in mortality. About 11% of all fractures occur in the femur and are usually treated operatively. Delay to operative treatment is a source of distress to patients and a major factor for poor outcome. Knowledge gaps exist for statistics on operative delay to fixation of femur fractures and the influence on complications and cost of treatment. This study describes (1) the effect of delay to fixation of femur fractures on complications and on the overall cost of care in hospitals in Quebec Province of Canada; and (2) proposes a time frame within which femur fractures should be operated on to minimize the risk of complications and reduce treatment cost. 6,520 adult patients operated for closed femoral fractures between July 1993 and December 2002 were reviewed. Data was accessed from (a) the Quebec Trauma Registry, (b) the hospitalised patients’ database, Maintenance et exploitation des données pour l’étude de la clientèle hospitalière (MED-ECHO) and (c) the medical insurance claims databases, Régie de l’assurance maladie Québec (RAMQ). Excluded were poly-trauma, open fractures, pathological fractures and delayed diagnoses beyond a week. Data was analysed using the SPSS software version 17.0. Cost analysis was carried out using parametric techniques (Student’s t-test and the generalized longitudinal model). Mean operative delay for femoral fractures was 26.3 hours. Delay was associated with increased complications, ICU stay, length of stay (LOS), hospitalization costs and out-patient follow-up treatment costs. There was a progressive increase in these adverse events which was quite significant after the first 48 hours. ISS >15 predisposed to prolonged ICU stay, LOS and increased cost of treatment. All femur fractures appeared to have a predilection for over-65-year-olds and women. The major cost drivers of operative femur fracture treatment were ISS>15, operative delay ≥48 hours, occurrence of complications, and re-operations. Minimizing operative delay in femur fractures will not only mitigate patient suffering, but also reduce treatment and follow-up costs

Introduction. Social determinants of health (SDOH) may contribute markedly to the total cost of care (COC) for patients undergoing elective total knee arthroplasty (TKA). This study investigated the association between demographics, health status, and SDOH on lengths of stay (LOS) and 30-day COC. Methods. Patients who underwent TKA between January 2018 and December 2019 were identified. Those who had complete SDOH data were utilized, leaving 234 patients. Data elements were drawn from the Chesapeake Regional Information System, the Center for Disease Control social vulnerability index (SVI), the Food Access Research Atlas (FARA). The SVI identifies areas vulnerable to catastrophic events, with 4 themed scores including: (1) socioeconomic status; (2) household composition and disability; (3) minority status and language; and (4) housing and transportation. Food deserts were defined as neighborhoods located 1 or 10 miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine an association with LOS and cost, after controlling for demographics. Results. Increased 30-day COC associated with SVI theme 3, (3.074 days; p=0.001) and patients who lived in a food desert ($53,205; p=0.001), as well as those who had anemia ($16,112; P = 0.038), chronic obstructive pulmonary disease ($32,570, P = 0.001), congestive heart failure ($30,927, P = 0.003), and dementia ($33,456, P = 0.008). Longer hospital lengths of stay were associated with SVI theme 3. In addition, patients who had anemia and congestive heart failure were at risk for longer hospital lengths of stay (P < 0.001, P = 0.001, respectively). Conclusion. Higher SVI theme 3 scores and living in food deserts were risk factors for increased LOS and costs, respectively. Identifying social factors including a patient's transportation options, living situation and access to healthy foods may prove to be both prognostic of outcomes and an opportunity for intervention

Aims. The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD. Methods. A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial. Results. Eight retrospective studies involving 29,738 patients with IBD were included. Compared with non-IBD controls, patients with IBD were significantly more likely to have overall complications (OR 2.11 (95% CI 1.67 to 2.66), p < 0.001), medical complications (OR 2.15 (95% CI 1.73 to 2.68), p < 0.001), surgical complications (OR 1.43 (95% CI 1.21 to 1.70), p < 0.001), and 90-day readmissions (OR 1.42 (95% CI 1.23 to 1.65), p < 0.001). The presence of IBD was positively associated with the development of venous thromboembolism (OR 1.60 (95% CI 1.30 to 1.97), p < 0.001) and postoperative infection (OR 1.95 (95% CI 1.51 to 2.51), p < 0.001). In addition, patients with IBD tended to experience longer LOS and higher costs of care. Conclusion. The findings suggest that IBD is associated with an increased risk of postoperative complications and readmission after joint arthroplasty, resulting in longer hospital stay and greater financial burden. Surgeons should inform their patients of the possibility of adverse outcomes prior to surgery and make appropriate risk adjustments to minimize potential complications. Cite this article: Bone Joint Res 2023;12(6):362–371

Introduction. The Center for Medicare and Medicaid Services (CMS) is faced with a challenge of decreasing the cost of care for total knee arthroplasty (TKA), but must make efforts to prevent patient selection bias in the process. Currently, no appropriate modifier codes exist for primary TKA based on case complexity. We sought to determine differences in perioperative parameters for patients with “complex” primary TKA with the hypothesis that they would require increased cost of care, prolonged care times, and have worse postoperative outcome metrics. Methods. We performed a single center retrospective review from 2015 to 2018 of all primary TKA. Patient demographics, medial proximal tibial angle (mPTA), lateral distal femoral angle (lDFA), flexion contracture, cost of care, and early postoperative outcomes were collected. ‘Complex’ patients were defined as those requiring stems or augments, and multivariable logistic regression analysis and propensity score matching were performed to evaluate perioperative outcomes. Results. 1046 primary TKA were studied and 84 patients (8.3%) were classified as “complex”. For this cohort, surgery duration was greater (117 vs 82 minutes; p<0.001), cost of care excessive (p<0.001), and patients had a greater likelihood for 90-day hospital return. Deviation of mPTA and lDFA was significantly greater preoperatively before and after propensity score matching. Cutpoint analysis demonstrated that preoperative mPTA <83o or >91o, lDFA <84o or >90o, flexion contracture >10o, and BMI > 35.7 were associated with ‘Complex’ procedures. Conclusions. Complex primary TKA may be identifiable preoperatively and are associated prolonged operative time, excess hospital cost of care and increased 90-day hospital returns. This should be considered in future reimbursement models to prevent patient selection bias, and a complexity modifier is warranted

With an ageing population and an increasing number of primary arthroplasties performed, the revision burden is predicted to increase. The aims of this study were to 1. Determine the revision burden in an academic hospital over a 11-year period; 2. identify the direct hospital cost associated with the delivery of revision service and 3. ascertain factors associated with increased cost. This is an IRB-approved, retrospective, single tertiary referral center, consecutive case series. Using the hospital data warehouse, all patients that underwent revision hip or knee arthroplasty surgery between 2008-2018 were identified. 1632 revisions were identified (1304 patients), consisting of 1061 hip and 571 knee revisions. The majority of revisions were performed for mechanical-related problems and aseptic loosening (n=903; 55.3%); followed by periprosthetic joint infection (n=553; 33.9%) and periprosthetic fractures (176; 10.8%). Cost and length of stay was determined for all patient. The direct in-hospital costs were converted to 2020 inflation-adjusted Canadian dollars. Several patients- (age; gender; HOMR- and ASA-scores; Hemoglobin level) and surgical- (indication for surgery; surgical site) factors were tested for possible associations. The number of revisions increased by 210% in the study period (2008 vs. 2018: 83 vs. 174). Revision indications changed over study period; with prevalence of fracture increasing by 460% (5 in 2008 vs. 23 in 2018) with an accompanying reduction in mechanical-related reasons, whilst revisions for infection remained constant. The mean annual cost over the entire study period was 3.9 MMCAD (range:2.4–5.1 MMCAD). The cost raised 150% over the study period from 2.4 MMCAD in 2008 to 3.6 MMCAD. Revisions for fractured had the greatest length of stay, the highest mean age, HOMR-score, ASA and cost associated with treatment compared to other revision indications (p < 0 .001). Patient factors associated with cost and length of stay included ASA- and HOMR-scores, Charlson-Comorbidity score and age. The revision burden increased 1.5-fold over the years and so has the direct cost of care delivery. The increased cost is primarily related to the prolonged hospital stay and increased surgical cost. For tertiary care units, these findings indicate a need to identify strategies on improving efficiencies whilst improving the quality of patient care (e.g. efficient ways of reducing acute hospital stay) and reducing the raise of the economic burden on a publicly funded health system

Introduction. Bundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services (CMS) have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center. Methods. This is a retrospective review of primary TKA patients from July 2015-December 2017. Patients were stratified by whether or not their surgery was performed before or after implementation of the CJR bundle. Patient demographic data including age, sex, and BMI were collected in addition to Elixhauser comorbidities and ASA score. In-hospital outcomes were then examined including surgery duration, length of stay, discharge disposition, and direct cost of care. Results. 1,248 TKA patients (546 Medicare and 702 Commercial Insurance) were evaluated, with 27.0% undergoing surgery prior to the start of the bundle. Compared to patients following implementation of the bundle, there was no significant difference in age, gender, or BMI. However, pre-CJR Medicare patients were more likely to have fewer Elixhauser comorbidities (p<0.001), prolonged length of stay (p<0.001), and greater discharges to inpatient facilities (p=0.019). There was no significant difference in direct hospital costs or operative service time comparing pre and post bundle patients. Conclusions. Implementation of the bundled reimbursement model did not result in biased patient selection at our institution; importantly, it also did not result in decreased hospital costs despite apparent improvement in value-based outcome metrics. This should be taken into consideration as future adaptations to reimbursement are made by CMS. For figures, tables, or references, please contact authors directly

Introduction. While total hip arthroplasty is considered to be one of the most cost-effective medical interventions, the total cost of care for a population patients treated by THR can present a significant burden on the payer, whether it be an employer, private insurer or government. Data on the true cost of care has rarely been made available to the treating physician. Such lack of information makes comprehensive management difficult. Bundled payment models of care require knowledge of all costs associated with the care of our patients and opens new opportunity for analysis to improve management and outcomes. The current study assess the influence of surgical technique on total cost of care for total hip arthroplasty. Methods. Payment data for 341 patients who underwent total hip arthroplasty at a single institution from June 1. st. , 2011 to October 31. st. , 2014 were analyzed. Each procedure was performed using either the superior, anterior, or posterior exposure. The superior exposure was performed with femoral head excision and without dislocation of the hip. The data were analyzed for total cost, inpatient cost, inpatient physician cost, readmission cost, skilled nursing facility cost, and home healthcare agency cost among the different approaches. Results. The superior hip approach for total hip arthroplasty results in a significant total cost savings over a 90-day episode of care when compared to both the anterior and posterior exposure techniques. It reduced overall costs by approximately $2,000 and $7,000 per case versus the other groups respectively. The superior approach also demonstrated savings in inpatient and skilled nursing facility cost when compared to the other groups. Conclusions. Surgical technique can have a profound influence on the total cost of care for hip arthroplasty patients. The current study demonstrates that the posterior exposure resulted in the largest consumption of resources post-operatively as measured by total cost of care and that the superior exposure resulted in the least consumption of resources among the three surgical exposures assessed. The study suggests that while we focus on many aspects of improvement in the overall episode of care for our patients, that focus on surgical technique may be worthwhile

Aims. Social determinants of health (SDOHs) may contribute to the total cost of care (TCOC) for patients undergoing total knee arthroplasty (TKA). The aim of this study was to investigate the association between demographic data, health status, and SDOHs on 30-day length of stay (LOS) and TCOC after this procedure. Methods. Patients who underwent TKA between 1 January 2018 and 31 December 2019 were identified. A total of 234 patients with complete SDOH data were included. Data were drawn from the Chesapeake Regional Information System, the Centers for Disease Control social vulnerability index (SVI), the US Department of Agriculture, and institutional electronic medical records. The SVI identifies areas vulnerable to catastrophic events with four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. Food deserts were defined as neighbourhoods located one or ten miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine associations with LOS and costs after controlling for various demographic parameters. Results. Divorced status was significantly associated with an increased LOS (p = 0.043). Comorbidities significantly associated with an increased LOS included chronic obstructive pulmonary disease/asthma and congestive heart failure (p = 0.043 and p = 0.001, respectively). Communities with a higher density of tobacco stores were significantly associated with an increased LOS (p = 0.017). Comorbidities significantly associated with an increased TCOC included chronic obstructive pulmonary disease (p = 0.004), dementia (p = 0.048), and heart failure (p = 0.007). Increased TCOCs were significantly associated with patients who lived in food deserts (p = 0.001) and in areas with an increased density of tobacco stores (p = 0.023). Conclusion. Divorced marital status was significantly associated with an increased LOS following TKA. Living in food deserts and in communities with more tobacco stores were significant risk factors for increased LOS and TCOC. Food access and ease of acquiring tobacco may both prove to be prognostic of outcome after TKA and an opportunity for intervention. Cite this article: Bone Joint J 2021;103-B(6 Supple A):113–118

Modern healthcare contracting is shifting the responsibility for improving quality, enhancing community health and controlling the total cost of care for patient populations from payers to providers. Population-based contracting involves capitated risk taken across an entire population, such that any included services within the contract are paid for by the risk-bearing entity throughout the term of the agreement. Under such contracts, a risk-bearing entity, which may be a provider group, a hospital or another payer, administers the contract and assumes risk for contractually defined services. These contracts can be structured in various ways, from professional fee capitation to full global per member per month diagnosis-based risk. The entity contracting with the payer must have downstream network contracts to provide the care and facilities that it has agreed to provide. Population health is a very powerful model to reduce waste and costs. It requires a deep understanding of the nuances of such contracting and the appropriate infrastructure to manage both networks and risk. Cite this article: Bone Joint J 2017;99-B:1431–4

Total knee and hip arthroplasty (TKA and THA) are two of the highest volume and resource intensive surgical procedures. Key drivers of the cost of surgical care are duration of surgery (DOS) and postoperative inpatient length of stay (LOS). The ability to predict TKA and THA DOS and LOS has substantial implications for hospital finances, scheduling and resource allocation. The goal of this study was to predict DOS and LOS for elective unilateral TKAs and THAs using machine learning models (MLMs) constructed on preoperative patient factors using a large North American database. The American College of Surgeons (ACS) National Surgical and Quality Improvement (NSQIP) database was queried for elective unilateral TKA and THA procedures from 2014-2019. The dataset was split into training, validation and testing based on year. Multiple conventional and deep MLMs such as linear, tree-based and multilayer perceptrons (MLPs) were constructed. The models with best performance on the validation set were evaluated on the testing set. Models were evaluated according to 1) mean squared error (MSE), 2) buffer accuracy (the number of times the predicted target was within a predesignated buffer of the actual target), and 3) classification accuracy (the number of times the correct class was predicted by the models). To ensure useful predictions, the results of the models were compared to a mean regressor. A total of 499,432 patients (TKA 302,490; THA 196,942) were included. The MLP models had the best MSEs and accuracy across both TKA and THA patients. During testing, the TKA MSEs for DOS and LOS were 0.893 and 0.688 while the THA MSEs for DOS and LOS were 0.895 and 0.691. The TKA DOS 30-minute buffer accuracy and ≤120 min, >120 min classification accuracy were 78.8% and 88.3%, while the TKA LOS 1-day buffer accuracy and ≤2 days, >2 days classification accuracy were 75.2% and 76.1%. The THA DOS 30-minute buffer accuracy and ≤120 min, >120 min classification accuracy were 81.6% and 91.4%, while the THA LOS 1-day buffer accuracy and ≤2 days, >2 days classification accuracy were 78.3% and 80.4%. All models across both TKA and THA patients were more accurate than the mean regressors for both DOS and LOS predictions across both buffer and classification accuracies. Conventional and deep MLMs have been effectively implemented to predict the DOS and LOS of elective unilateral TKA and THA patients based on preoperative patient factors using a large North American database with a high level of accuracy. Future work should include using operational factors to further refine these models and improve predictive accuracy. Results of this work will allow institutions to optimize their resource allocation, reduce costs and improve surgical scheduling. Acknowledgements:. The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors

Background. Cementless femoral fixation in total hip arthroplasty (THA) continues to rise worldwide, accompanied by the increasing abandonment of cemented femoral fixation. Cementless fixation is known to contribute to higher rates of post-operative complications and reoperations. New data is available from the Centers for Medicare and Medicaid Services (CMS) regarding total costs of care from the Bundled Payment for Care Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) initiatives. Questions/purposes. How does femoral fixation affect (1) 90-day costs; (2) readmission rates; (3) re-operation rates; (4) length of stay (LOS); and (5) discharge disposition for Medicare patients undergoing elective or non-elective THA?. Methods. We performed a retrospective review of 1671 primary THA cases in Medicare patients across nine hospitals in an academic healthcare network. CMS data was used to evaluate lump costs including the surgical admission and 30-day or 90-day post-operative episodes. Costs were then correlated with clinical outcome measures from review of our electronic medical record. Demographic differences were present between the cemented and cementless cohorts. Statistical analyses were performed including multiple regression models adjusted for the baseline cohort differences. Results. After controlling for confounding variables, cemented patients were significantly more likely to be discharged home compared to cementless patients. Cemented femoral fixation also demonstrated a trend towards lower costs, fewer readmissions and shorter LOS. All of the reoperations within the early postoperative period occurred in cementless patients. Conclusion. In a large Medicare population, cemented femoral fixation outperformed cementless fixation with respect to discharge disposition and also trended toward superiority with regards to LOS, readmission, cost of care, and reoperations. Cemented femoral fixation remains relevant and useful despite the rising popularity of cementless fixation. Orthopaedic surgeons in training should become competent with femoral cementation technique

To compare the costs of treatment and income received for treating patients with tibial osteomyelitis, comparing limb salvage with amputation. We derived direct hospital costs of care for ten consecutive patients treated with limb salvage procedures and five consecutive patients who underwent amputation, for tibial osteomyelitis. We recorded all factors which affect the cost of treatment. Financial data from the Patient-Level Information and Costing System (PLICS) allowed calculation of hospital costs and income received from payment under the UK National Tariff. Hospital payment is based on primary diagnosis, operation code, length of stay, patient co-morbidities and supplements for custom implants or external fixators. Our primary outcome measure was net income/loss for each in-patient episode. The mean age of patients undergoing limb salvage was 55 years (range 34–83 years) whereas for amputation this was 61 years (range 51–83 years). Both groups were similar in Cierny and Mader Staging, requirement for soft-tissue reconstruction, anaesthetic technique, diagnostics, drug administration and antibiotic therapy. In the limb salvage group, there were two infected non-unions requiring Ilizarov method and five free flaps. Mean hospital stay was 15 days (10–27). Mean direct cost of care was €16,718 and mean income was €9,105, resulting in an average net loss of €7,613 per patient. Patients undergoing segmental resection with Ilizarov bifocal reconstruction and those with the longest length of stay generated the greatest net loss. In the amputation group, there were 3 above knee and 2 below knee amputations for failed previous treatment of osteomyelitis or infected non-union. Mean hospital stay was 13 days (8–17). Mean direct cost of care was €18,441 and mean income was €15,707, resulting in an average net loss of €2,734 per patient. Length of stay was directly proportional to net loss. The UK National Tariff structure does not provide sufficient funding for treatment of osteomyelitis of the tibia by either reconstruction or amputation. Average income for a patient admitted for limb salvage is €6,602 less than that for amputation even though the surgery is frequently more technically demanding (often requiring complex bone reconstruction and free tissue transfer) and the length of hospital stay is longer. Although both are significantly loss-making, the net loss for limb salvage is more than double that for amputation. This makes treatment of tibial osteomyelitis in the UK National Health Service unsustainable in the long term

Introduction. Alternative payment models for total hip arthroplasty (THA) were initiated by the Center for Medicare and Medicaid Services (CMS) to decrease overall healthcare cost by optimizing healthcare delivery. The associated shift of financial risk to participating institutions has been criticized to introduce patient selection in order to avoid potentially high cost of care. This study aimed to evaluate the impact of the Comprehensive Care for Joint Replacement (CJR) model on patient selection, care delivery and hospital costs at a single care center. Methods. This is a retrospective review of THA patient from July 2015-December 2017 was performed. Patient were stratified by insurance type (Medicare and commercial insurance) and whether care was provided before or after implementation of the CJR bundle. Patient age, gender, and BMI, as well as Elixhauser comorbidities and ASA scores were analyzed. Delivery of care variables including surgery duration, discharge disposition, length of stay, and direct hospital costs were compared before and after CJR implementation. Results. 751 THA patients (273 Medicare and 478 Commercial Insurance) were evaluated before (29%) and after (71%) CJR bundle implementation. There was no difference in patient demographics (age, gender, or BMI); however, commercially insured patients had less Elxihauser comorbidies pre-bundle (p=0.033). After CJR implementation length of stay (p=0.010) for Medicare patients was reduced with a trend toward discharge to home (p=0.019). However, surgical time and OR service time as well as direct hospital costs were similar before and after the CJR bundle initiation. Conclusions. There was no differential patient selection after CJR bundle implementation, and value-based metrics (surgical time, OR service time) were not affected. Patients were discharged sooner and more often to home. However, overall direct hospital expenses remained unchanged revealing that any cost savings were for insurance providers, not participating hospitals. For any tables or figures, please contact the authors directly

Aims. This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma Evaluation (WHiTE)) in the UK. Methods. A questionnaire containing health resource use was completed at baseline and four months post-injury by patients or their carer. Completion rate and mean cost of each health resource item were assessed and sensitivity analysis was performed to derive a conservative estimate of the informal care cost. All costs are presented in 2017/18 pound sterling. Results. A total of 4,183 patients from the WHiTE cohort completed the baseline questionnaire between May 2017 and April 2018, of whom 3,524 (84.2%) completed the four-month health resource section. Estimated mean costs of formal and informal care, home adaptations, and physiotherapy during the four months following injury were £2,843 (SD 5,467), £6,613 (SD 15,146), £706 (SD 1,706) and £9 (SD 33), respectively. Mean cost of informal care decreased to £660 (SD £1,040) in the sensitivity analysis when informal care was capped at 17.2 hours per day. Conclusion. Informal care is a significant source of costs after hip fracture and should therefore be included in future economical analyses of this patient group. Our results show that there is considerable variation in the interpretation of time-use of informal care among patients and further work is needed to improve how data regarding informal care are collected in order to obtain a more accurate cost estimate. Cite this article: Bone Joint Res. 2020;9(5):250–257

The high and ever increasing cost of medical care worldwide has driven a trend toward new payment models. Event based models (such as bundled payment for surgical events) have shown a greater potential for care and cost improvement than population-based models (such as accountable care organizations). Since joint replacement is among the most frequent and costly surgical events in medicine, bundled payments for joint replacement episodes have been at the forefront of evolution from fee-for-service to value-based care models and episode-based healthcare reform in general. Our education as surgeons in medical school, residency, fellowship, and in continuing education has been almost entirely non-economic in focus. Yet, we surgeons are now evolving from being primarily responsive for our patients' medical care to being also responsible for all expenditures associated with our patients' care. Similarly, while the cost of our patients' care was not even available to us, every dollar of expenditure for a patient's episode of care is now available to us in some circumstances. For example, a typical primary joint replacement episode may cost $30,000 for a patient insured by Medicare in the US. A surgeon performing 400 joint replacements per year is therefore authorizing upwards of $12M a year in health care spending by making the decisions to perform reconstructive procedures on those patients. The risk for value-based surgical episodes of care can be born by various entities including hospital systems or the surgeons themselves. Recent evidence demonstrates that quality improves and cost decreases more rapidly when surgeons take primary responsibility and risk for episodes of care as compared to when a hospital system or third party takes primary responsibility and risk. Yet, as surgeons, our education in the field of medical economics, value-based episodes of care, and payment reform is only just beginning. The more we understand about the cost and value of the services that we order for our patients, the more leadership can provide as healthcare evolves. The current presentation will describe the specific cost of care for the primary joint replacement patient preliminary experience with accepting risk and responsibility for these patients. It is likely that our patients will be best served if we surgeons provide as much leadership as possible in their care, both medically and economically

BACKGROUND. Telerehabilitation has been shown to both promote effective recovery after shoulder arthroplasty and may improve adherence to treatment. Such systems require demonstration of feasibility, ease of use, efficacy, patient and clinician satisfaction, and overall cost of care, and much of this data has yet to be provided. Few augmented reality rehabilitation approaches have been developed to date. Evidence suggests augmented reality rehabilitation may be equivalent to conventional methods for adherence, improvement of function, and relief of pain seen in these musculoskeletal conditions. We proposed that the development of an augmented reality rehabilitation platform during the pre and postoperative period (including post-shoulder arthroplasty) could be used to track patient activity and range of motion as well as promote recovery. METHODS. A prototype augmented reality platform equipped with a motion sensor system optimised for the upper arm was developed to be used to validate 4 arcs of shoulder motion and complete directed upper arm exercises designed for post-shoulder arthroplasty rehabilitation was built and tested. This system combined augmented reality instructions and motion tracking to follow patients over the course of their therapy, along with a telehealth patient-clinician interface. FINDINGS. The augmented reality platform was tested to validate shoulder range of motion examination similar to that of standard goniometer measurements. Healthy test subjects without shoulder pain or prior shoulder surgery performed the arcs of motion for 5 repetitions as part of a home therapy program. Each motion was measured with angular measurements as a proof of concept with high degree precision (less than 5 degrees). Remote patient-clinician interface testing was also conducted along with a clinician established therapy plan. DISCUSSION. Augmented reality systems that track patients' complex movements, including clinical shoulder range of motion, suggest the promising future of telerehabilitation in arthroplasty, particularly in telemonitoring before and after surgery. As this technology continues to gain acceptance, further studies that evaluate the outcomes of augmented reality rehabilitation for long-term follow-up are needed

Introduction. Close to 30% of the surgical causes of readmission within 90 days post-total knee arthroplasty (TKA) and nearly half of those occurring in the first 2 years are caused by instability, arthrofibrosis, and malalignment, all of which may be addressed by improving knee balance. Furthermore, the recently launched Comprehensive Care for Joint Replacement (CJR) initiative mandates that any increase in post-acute care costs through 90-days post-discharge will come directly from the bundle payment paid to providers. Post-discharge costs, including the cost of readmissions for complications are one of the largest drivers of the 90-day cost of care. It is hypothesized that balanced knees post-TKA will lower the true provider costs within the 90-day bundle. Methods. Cost, outcomes and resource utilization data were collected from three independent surgeons pre- and post- adoption of intraoperative technology developed to provide real-time, quantitative load data within the knee. In addition, data were collected from Medicare claims, hospital records, electronic medical records (EMR), clinical, and specialty databases. The cohorts consisted of 932 patients in the pre-adoption group and 709 patients in the post-adoption group. These 2 groups were compared to the CMS national average data from 291,201 cases. The groups were controlled for age, sex, state, and BMI with no major differences between cohorts. The cost factors considered were the length of hospital stay, physician visits and physical therapy visits in addition to post-operative complications (e.g., manipulation under anesthesia (MUA) and aseptic revision). Results. After adoption of technology to improve ligament balancing intra-operatively, all three surgeons decreased their patients’ hospital stay (3.0 days to 2.6 days), number of physician visits (2.3 to 2.1), number of outpatient physical therapy visits (14.9 to 10.6) and MUA rate (2.3% to 1.8%). These clinical benefits subsequently lowered the 90-day net cost of TKA an average of $443 per case. When compared to the national average, this cost savings was $725 per case. Conclusions. Appropriately balancing TKA patients intra-operatively might help mitigate costs associated with TKA procedures within the 90-day bundle. In this study, it was found that using new joint balancing technology generated a substantial cost-savings post-discharge, primarily due to patients requiring less outpatient physical therapy

Introduction. The Comprehensive Care for Joint Replacement (CJR) model for total hip arthroplasty (THA) involves a target reimbursement set by the Center for Medicare and Medicaid Services (CMS). Many patients exceed these targets, but predicting risk for incurring these excess costs remains challenging, and we hypothesized that select patient characteristics would adequately predict CJR cost overruns. Methods. Demographic factors and comorbidities were retrospectively reviewed in 863 primary unilateral CJR THAs performed between 2013 and 2017 at a single institution. A predictive model was built from 31 validated comorbidities and a base set of 5 patient factors (age, gender, BMI, ASA, marital status). A multivariable logistic regression model was refined to include only parameters predictive of exceeding the target reimbursement level. These were then assigned weights relative to the weakest parameter in the model. Results. The overall cost of care for 225 patients (26.1%) exceeded the target price, and a comprehensive model containing all 36 parameters demonstrated adequate discrimination (AUC: 0.748). This model was narrowed to 12 parameters retained for their statistical value in predicting excess cost, without substantial loss of predictive ability (AUC: 0.735). A single score formed from the sum of each patient's weighted parameters also showed adequate discrimination (AUC: .732), with predicted risk for exceeding CJR targets ranging from 10% for a patient score of 10 to 80% for a score of 30. Average scores for patients exceeding the target price were significantly higher than those who did not (19.5 vs 15.0, p < 0.0001). Conclusions. A model composed of weighted comorbidities and base demographics provides adequate discrimination in predicting whether THA costs will exceed CJR targets. This not only helps identify patients who may benefit from further pre-operative optimization, but also allows health systems to predict the likely minimum incurred costs for select patients scheduled for surgery

Abstract. Objectives. The purpose of this study was to determine the cost of inpatient admissions for developmental dysplasia of the hip (DDH) at a UK tertiary referral centre, and identify any association between newborn screening (NIPE) status and the cost of treatment. Methods. This was a retrospective study, using hospital episodes data from a single NHS trust. All inpatient episodes between 01/01/2014 to 30/06/2019 with an ICD-10 code stem of Q65 ‘congenital deformities of hip’ were screened to identify admissions for management of DDH. Data was subsequently obtained from electronic and paper records. Newborn screening status was recorded, and patients were divided into ‘NIPE-positive’ (diagnosed through selective screening) and ‘NIPE-negative’ (not diagnosed through screening). Children with neuromuscular conditions or concomitant musculoskeletal disease were excluded. The tariff paid for each inpatient episode was identified, and the number of individual clinic attendances, surgical procedures and radiological examinations performed (USS, XR, CT, MRI) were recorded. Results. 41 patients with DDH were admitted for inpatient management. 44% (n = 18) were NIPE-positive, diagnosed mean age 6.7 weeks. 56% (n = 23) were NIPE-negative, diagnosed mean age 26 months. The total cost of inpatient care in the NIPE-positive group was £171,471 (£9,526.18 per-patient) compared to £306,615 (£13,331.10 per-patient) for NIPE-negative. In the NIPE-positive group, there were 99 clinic attendances, 47 inpatient admissions and 160 radiological examinations performed (36 USS, 107 XR, 17 CT). This compared to 148 clinic attendances, 59 inpatient admissions and 215 radiological examinations (187 XR, 26 CT, 2 MRI) in the NIPE-negative group. Conclusion. A greater proportion of inpatient admissions for DDH are among NIPE-negative children. They incur a higher cost of treatment per patient and necessitate more inpatient resources. This study adds to the ongoing conversation around the cost-effectiveness of selective screening for DDH in the UK. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project