Patient safety is a critical issue in elective total joint replacement surgery. Identifying risk factors that might predict complications and intensive care unit (ICU) admission proves instrumental in reducing morbidity and mortality. The institution’s experience with risk stratification and pre-operative ICU triage has resulted in a reduction in unplanned ICU admissions and post-operative complications after total hip replacement. The application of the prediction tools to total knee replacement has proven less robust so far. This work also reviews areas for future research in patient safety and cost containment. . Cite this article: Bone Joint J 2013;95-B, Supple A:74–6

Aims

The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS.

Background. Delay in access to primary total hip (THA) arthroplasty continues to pose a substantial burden to patients and society in publicly funded healthcare systems. The majority of strategies to decrease wait times have focused on the time from surgical consult to surgery, however a large proportion of total wait time for these patients is the time from primary care referral to surgical consultation. Prioritization scoring tools and patient reported outcome measures are being used in an attempt to ration limited resources in the face of increasing demand. However, to our knowledge, no study has investigated whether a referral Oxford Hip Score (OHS) could be used to triage non-surgical referrals appropriately, in an effort to increase timely access to specialists for patients that are candidates for total joint replacement (TJR). Purpose. 1) To determine if a referral OHS has the predictive ability to discriminate when a hip patient will be deemed surgical versus conservative by the surgeon during their first consultation 2) To identify an OHS cut-off point that can be used to accurately predict when a primary THA referral will be deemed conservative by the consultant surgeon during the first consultation. Methods. We retrospectively reviewed all consecutive THA consultations from a single surgeon's tertiary, high volume practice over a 3-year period. Patients with a pre-consultation OHS, BMI <41, and no absolute contraindication to TJR were included. Consultation were categorized into two groups based on surgeon's decision, those that were offered THR during their first consultation (operative) versus those that were not (conservative). Baseline demographic data and OHS were abstracted. Variables of interest were compared between cohorts using the exact chi-square test and Wilcoxon rank-sum test. Spearman's rank correlation coefficients were used to measure association between pre-consult OHS and the surgeon's decision. A receiver operator characteristic (ROC) curve analysis was used to calculate the area under the curve (AUC) and to identify a cut-off point for the pre-operative OHS that identified whether or not a referral was deemed conservative. Results. The study 478 hips (388 patients) with a median OHS of 22 (IQR 16–29). Median pre-consultation OHS demonstrated clinically and statistically significant differences between the surgical versus conservative cohorts (p<0.001). Spearman's rank correlation coefficient between OHS and a patient being deemed surgical or conservative was strong for the OHS at −0.62 (95% CI −0.67 to −0.56). The ROC AUC values for hip consults (0.87, 95% CI 0.84–0.91) was good, indicating that pre-consult OHS has predictive ability to discriminate a surgeon's decision of surgical versus conservative. One plausible conservative threshold that optimized sensitivity and NPV for hips is OHS >34 (sensitivity=0.997 NPV=0.978). ROC analysis identified severable potential lower, depending on weight of prioritization of sensitivity, specificity, and NPV. Conclusion. Referral OHS demonstrate good ability to discriminate when a knee or hip TJR referral will be deemed non-surgical versus surgical at their first consultation in a single surgeon's practice. Multiple potential OHS thresholds can be applied as a tool to decrease wait times for primary THR. However, a cost analysis would aid in identifying the optimal cut-off score, and these findings need to be validated with multi-surgeon/center studies before they can be broadly applied

Nobel Prize winning economist Paul Krugman described Moral Hazard as “…any situation in which one person makes the decision about how much risk to take, while someone else bears the cost if things go badly”. The fidelity of some surgeons to their patients has been brought into question by recent press reports exposing a practice whereby one attending surgeon will be responsible for two patients undergoing surgery simultaneously. This is variously referred to as Overlapping Surgery, Concurrent Surgery, Simultaneous Surgery, Double-Booked Surgery or Ghost Surgery. This practice entails surgeons in training (residents and fellows) performing varying degrees of the patient's surgery while the attending surgeon is operating elsewhere. In general, the patient is not informed of this substitution. When informed, most would not allow it. Defenders of this practice site surgeon and hospital “efficiency”, independent operating experience by trainees, mass casualty triage and access to “in-demand” specialists. Critics feel it “is a breach of ethical behavior”, that “The most likely motive for this is profit for both the surgeon and hospital” and “Overlapping surgery… threatens our obligation as orthopaedic surgeons to respect the primacy of patient welfare…”. The American College of Surgeons, in response to public disclosures, created a policy on Overlapping Surgery. Its executive director wrote, “It is essential that the patient be informed of this practice and given enough notice so they may decide whether to seek care from another surgeon or at another institution*. The US Senate Finance Committee investigated Overlapping/Concurrent Surgery practices. It expressed concerns over − 1) lack of informed consent, 2) plausible risks to patient safety, 3) use of Medicare billing regulations to determine acceptable surgical practices and 4) surgeons self- defining the “critical part” of the operation. Studies to date do not resolve the propriety of this practice. All but one is short term. Most show longer surgical durations. Most show no increase in 30-day complication rates. The only long- term study found a 90% increase in complication rate in hip procedures at one year when surgery overlapped. None document the location of the surgeon during the procedure or report efficacy. Over 7 million living Americans are beneficiaries of either a total hip or total knee replacement. These patients are made whole, their suffering relieved, their function and lives restored. These miracles of modern medicine are not without cost. The United States spends $3.5 trillion dollars annually on health care, almost 20% of our GDP. Delivering health care is a grave responsibility and any person involved in it must understand the importance and consequences of their actions. The third leading cause of American deaths is medical errors. A recent study estimated that 4 out of 100 patients entering the hospital for surgery will die within seven days. Recognizing this, a surgeon's role as a patient's moral fiduciary, concerned primarily with protecting the interests of the patient, must be honored as a sacred trust. The financial pressure on the surgeon from stagnant surgical fees is the elephant in the room that must be addressed in relation to this matter. When fees are cut, surgeons operate more. Plato, in The Republic, recounts an allegory about a magic ring that makes its wearer invisible. He asks the question; Will the power of anonymity eliminate morality and ethics? When we as surgeons become “invisible” to our anesthetized patients during surgery, how will we answer that question?

Aims

The aim of this study was to determine if the Oxford Knee and Hip Score (OKHS) can accurately predict when a primary knee or hip referral is deemed nonsurgical versus surgical by the surgeon during their first consultation, and to identify nonsurgical OKHS screening thresholds.

To assess the sustainability of our institutional bone bank, we calculated the final product cost of fresh-frozen femoral head allografts and compared these costs with the use of commercial alternatives. Between 2007 and 2010 all quantifiable costs associated with allograft donor screening, harvesting, storage, and administration of femoral head allografts retrieved from patients undergoing elective hip replacement were analysed.

From 290 femoral head allografts harvested and stored as full (complete) head specimens or as two halves, 101 had to be withdrawn. In total, 104 full and 75 half heads were implanted in 152 recipients. The calculated final product costs were €1367 per full head. Compared with the use of commercially available processed allografts, a saving of at least €43 119 was realised over four-years (€10 780 per year) resulting in a cost-effective intervention at our institution. Assuming a price of between €1672 and €2149 per commercially purchased allograft, breakeven analysis revealed that implanting between 34 and 63 allografts per year equated to the total cost of bone banking.

Cite this article: Bone Joint J 2014;96-B:1307–11