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

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

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

Introduction. Reoperation within thirty days after hip fracture surgery is associated with increased mortality, length of stay and cost of care. The United Kingdom National Hip Fracture Database (NHFD) reported a significant increase in the 30-day reoperation rate for patients undergoing surgery for hip fractures in our unit from 2012 to 2014. We audited our data in order to validate this and identify any reversible trends. Methods. Between January 2012 and December 2014, 1757 consecutive procedures for hip fracture were performed in our unit. Patients who had a reoperation within 30 days and those recorded as ‘unknown’ under the reoperation category were identified. Patients with hip dislocations were included. Patient demographics, diagnosis, treatment and outcomes were recorded. This was compared with reoperation for all causes after 30 days over a 12-month period. Results. Nineteen patients (1.1%) underwent a reoperation within 30-days. There was no significant change in the annual incidence over the period studied. Infection was the leading cause for reoperation (47%). The NHFD also reported a 10-fold increase in the incidence of periprosthetic fractures during the study period (0.18% to 1.78%). This did not correlate with our findings (0% to 0.36%). Our NHFD data entry system was unchanged over the 3-year period. We identified a change in NHFD data entry form in April 2014 which corresponded to the increase in the incidence of periprosthetic fractures and overall reoperation rates. Discussion. These results suggest there is a need for local validation of NHFD data. The current design may contribute to imprecise data recording. We suggest the introduction of an automatic notification system informing the local NHFD lead of any reoperation within 30 days would assist in real-time monitoring. This study led us to identify infection as the leading cause of reoperation at our institution and initiate improvement measures

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The aim of this study was to compare the cost-effectiveness of cemented hemiarthroplasty (HA) versus hydroxyapatite-coated uncemented HA for the treatment of displaced intracapsular hip fractures in older adults.

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The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England.

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We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon.

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The primary aim of this paper was to outline the processes involved in building the Partners Arthroplasty Registry (PAR), established in April 2016 to capture baseline and outcome data for patients undergoing arthroplasty in a regional healthcare system. A secondary aim was to determine the quality of PAR’s data. A tertiary aim was to report preliminary findings from the registry and contributions to quality improvement initiatives and research up to March 2019.

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This paper describes the methods applied to assess the cost-effectiveness of cemented versus uncemented hemiarthroplasty among hip fracture patients in the World Hip Trauma Evaluation Five (WHiTE5) trial.