Aims. Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days. Methods. This observational study used routine clinical data in a consecutive sample of hip fracture patients aged ≥ 50 years admitted to a single large trauma centre during the COVID-19 pandemic between 1 March 2020 and 30 November 2021. Delirium was prospectively assessed as part of routine care by the 4 A’s Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, Scottish Index of Multiple Deprivation quintile, COVID-19 infection within 30 days, and American Society of Anesthesiologists grade. Results. A total of 1,821 patients were admitted, with 1,383 (mean age 79.5 years; 72.1% female) directly from home. Overall, 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1,734): 14.1% (189/1,340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20-day longer total length of stay (p < 0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (odds ratio (OR) 1.69 (95% confidence interval (CI) 1.13 to 2.54); p = 0.013), requirement for post-acute inpatient rehabilitation (OR 2.80 (95% CI 1.97 to 3.96); p < 0.001), and readmission to hospital within 180 days (OR 1.79 (95% CI 1.02 to 3.15); p = 0.041). Conclusion. Delirium affects one in seven patients with a hip fracture admitted directly from home, and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care. Cite this article: Bone Jt Open 2023;4(6):447–456

Aims. The Clavien-Dindo (CD) classification and Comprehensive Complication Index (CCI) have been validated primarily among general surgical procedures. To date, the validity of these measures has not been assessed in patients undergoing arthroplasty. Methods. This retrospective cohort study included patients undergoing primary total hip and knee arthroplasty between April 2013 and December 2019. Complications within 90 days of surgery were graded using the CD classification and converted to CCI. Validity was established by assessing the association between both measures and discharge to inpatient rehabilitation, length of stay, and costs. Results. Among 2,884 patients, 414 (14.4%) had an in-hospital complication and 643 (22.3%) had a complication within 90 days. Each increase in CD grade was associated with USD$1,895.48 (95% CI 1,734.77 to 2,056.18) of additional costs, an additional 1.24 days’ length of stay (95% CI 1.15 to 1.33), and 43% (95% CI 26 to 62%) greater odds of discharge to inpatient rehabilitation. Each ten-unit increase in CCI score was associated with USD$1,698.55 (95% CI 1,561.8 to 1,835.3) higher costs, an additional 1.09 days’ length of stay (95% CI 1.02 to 1.17), and 33% (95% CI 19% to 49%) greater odds of discharge to inpatient rehabilitation. Conclusion. Both the CD classification and CCI appear valid and applicable to patients undergoing total joint replacement. Cite this article: Bone Joint J 2025;107-B(1):81–88

Obesity is associated with worse outcomes following total knee/hip arthroplasty (TKA/TKA). This study aimed to determine the feasibility of a dietitian-led low-inflammatory weight-loss program for people with obesity awaiting arthroplasty. Quasi-experimental pilot study enrolled people with obesity waitlisted for primary TKA/THA into ‘usual care’ (UC) or weight-loss (low-inflammatory diet) program (Diet). Recruitment occurred between July 2019 and February 2020 at Fairfield and Campbelltown Hospitals. Assessments at baseline, pre-surgery, time of surgery and 90-days following surgery included anthropometric measurements, patient-reported outcomes, serum biomarkers and 90-day postoperative complication rate. 97 people consented to the study (UC, n=47, mean age 67, BMI 37, TKA 79%; Diet, n=50, mean age 66, BMI 36, TKA 72%). Baseline characteristics indicated gross joint impairments and poor compliance with a low-inflammatory diet. Study feasibility criteria included recruitment rate (52%), proportion of diet patients that improved compliance to low-inflammatory diet by ≥10% (57%) and had ≥60% attendance of dietitian consultations (72%), proportion of patients who undertook serum biomarkers (55%). By presurgery assessments, the diet group had more patients who cancelled their surgery due to symptom improvement (4 vs 0), reduced waist-circumference measurements, increased compliance with the Low-Inflammatory diet and preservation of physical activity parameters. More usual care participants experienced at least one postoperative complication to 90-days (59% vs 47%) and were discharged to inpatient rehabilitation (21% vs 11%). There was no difference in weight change, physical function, and patient-reported outcome measures from pre-surgery to 90-days post-surgery, and length of hospital stay. Using pre-determined feasibility criteria, conducting a definitive trial is not feasible. However, intervention audit demonstrated high intervention fidelity. Pilot data suggest our program may promote weight loss but the clinical effects for most are modest. Further research utilising a stronger intervention may be required to assess the effectiveness of a pre-arthroplasty weight-loss intervention

Home- based rehab is increasingly utilized to save costs but concerns have been raised about early hospital discharge and adverse clinical outcomes. This study compares the efficacy and patient satisfaction of home- based verses inpatient rehabilitation following total joint arthroplasty (TJA). Despite concerns about early hospital discharge there was no difference in functional outcomes and in patient satisfaction with procedure at the primary endpoints, between the groups receiving home based verses inpatient rehabilitation. This study compares the efficacy and patient satisfaction of home- based verses inpatient rehabilitation following total joint arthroplasty (TJA). Given that home- based rehab is less expensive, we would recommend the use of home based rehab protocols following elective primary TJA. Home- based rehab is increasingly utilized to save costs but concerns have been raised about early hospital discharge and adverse clinical outcomes. The groups were similar at baseline for patient demographics and WOMAC scores. At the six weeks, twelve weeks and one- year follow-up post TJA there was no statistically significant difference in WOMAC pain, physical function, stiffness and overall WOMAC scores. Both groups showed a trend of decrease in pain, stiffness, restriction in physical function over the follow-up period. Similarly, patient satisfaction scores at six, twelve weeks and one year did not show a statistically significant difference between the home versus inpatient group (P> 0.05). Two hundred and thirty-four patients were randomized to either home based or inpatient rehabilitation following TJA, using block randomization techniques. Standardized care pathways were followed for both procedures. All patients were evaluated at baseline (two weeks prior to surgery), six weeks, twelve weeks and one- year post surgery using standardized questionnaires. Primary outcomes were the self-reported WOMAC pain and function score and satisfaction in terms of improvement in pain and function. Despite concerns about early hospital discharge there was no difference in functional outcomes and in patient satisfaction with procedure at the primary endpoints, between the groups receiving home based verses inpatient rehabilitation. Funding: PSI

The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document. Background. The Bundled Payments for Care Improvement (BPCI) initiative was introduced to reduce healthcare costs while maintaining quality. We examined data from a healthcare system comprised of five hospitals that elected to participate in the BPCI Major Joint Replacement of the Lower Extremity Model 2 initiative beginning July 1, 2015. We compared one hospital that did 507 BPCI knee cases to the four other hospitals that did 566 cases. Stratifying the data by hospital volume, we sought to determine if costs decreased during the BPCI period, how the savings were achieved, and if savings resulted in financial rewards for participation. Methods. The Medicare data included the target cost for each episode (based on historical data from 2009–2012 for each hospital that was adjusted quarterly) and actual Part A and Part B spending for 90 days. Using 1,836 primary knee replacements, we analyzed the costs associated with the anchor hospitalization, inpatient rehabilitation, skilled nursing facilities, home health, outpatient physical therapy and readmission to compare the 1,073 knees done during the 16-month BPCI initiative period with the 763 knees done during the 1-year period preceding BPCI participation. Owing to the nonparametric distribution of the cost data, a Mann-Whitney U test was used to compare the higher volume hospital with the four lower volume hospitals. Results. Compared to the preceding year, the mean episode of care cost during BPCI participation decreased by 8.5% (from $20,853 to $19,087, p=0.24) at the higher volume hospital while remaining virtually unchanged (going from $20,383 to $20,380, p=0.10) at the lower volume hospitals. During the BPCI period, the mean Medicare 90-day target cost was $18,307 at the higher volume hospital and $22,287 at the lower volume hospitals (p<0.001). At the higher volume hospital, the major components of the savings included $367,290 from reduced readmission rates (5.7% versus 8.7%, p=0.11), $207,608 primarily due to a reduction in the length of stay at skilled nursing facilities (mean 15 days versus 25 days, p=0.005), and $130,894 associated with a decreased percentage of patients using inpatient rehabilitation (3.2% versus 4.9%, p=0.22). Although offset by other cost increases, the largest component of the savings at the lower volume hospitals was $262,548 due to a decrease in the percentage of patients (2.3% versus 4.8%, p=0.04) using inpatient rehabilitation. Despite its savings, the mean reconciliation penalty was $851 per case at the higher volume hospital while the lower volume hospitals received a mean reward of $2,165 per case. Conclusion. Based on the reduction in costs and decreased readmission rates, the BPCI initiative is achieving its objectives. Despite an 8.5% decrease in costs, the $18,307 target based on historical data resulted in an $851 penalty per case at the higher volume hospital. In contrast, as a result of a $3,980 higher target, the lower volume hospitals were rewarded even though they did not achieve cost savings. As structured, there is no incentive for centers with historically low costs to participate in BPCI

Significance: Since DRG-based Medicare payments to hospitals, length of stay (LOS) after Total Knee Arthroplasty (TKA) has declined dramatically. This reduction was accomplished in part by transferring patients to DRG-exempt rehabilitation units. Despite the regular use and expense of inpatient rehabilitation after TKA, there have been no prospective studies defining its efficacy. Purpose: Determine the impact of inpatient rehabilitation on TKA outcome. Methods: Prospective, observational, single surgeon, single facility design.Inclusion criteria:primary,cemented TKA for OA between 1998–1999. All postoperative and rehabilitative care dictated by clinical protocol. Subjects were evaluated pre-op, at 1,3 and 6 months post-op. Patient (demographics, comorbidities), psychological (depression, anxiety), surgical (implant type, fixation, alignment), resource utilization (LOS, outpatient/home PT visits, rehabilitation LOS), complications, functional (knee flexion, gait, assistive device, Knee Society Score (KSS)) and pain (visual analogue scale, medication use) data obtained. Principle outcomes were pain, knee flexion, function, KSS, number of PT visits. Results: 125 knees, 56 bilateral. No patient lost to follow-up. Mean age 66 years (36–85). At six months follow-up, postoperative KSS score was 164.4(94–200), flexion 114.3(80–130), VAS 18(SD 21). Patients discharged to rehabilitation had significantly lower preoperative KSS scores (89, SD30) than those discharged to home (104.6, SD24.4)p=035. There were no other differences between groups. Patients discharged directly to home had a greater knee flexion (p=005), walk farther (p=024), climb stairs easier (p=036), and utilized less home physical therapy (p=030) than patients discharged to rehabilitation. Conclusion: This study was unable to demonstrate a benefit of inpatient rehabilitation after TKA. However, patients transferred to inpatient rehabilitation were less functional before surgery than those discharged home. Further studies are needed to determine if these patients benefit from inpatient rehabilitation versus home care

Introduction. Provision of prehabilitation prior to total knee arthroplasty (TKA) through a digital mobile application is a novel concept. The primary aim of our research is to determine whether provision of prehabilitation through a mobile digital application impacts length of stay (LOS), requirement for inpatient rehabilitation and hospital-associated costs after TKA. Our study hypothesis is that a mobile digital application provides a low resource, cost effective method of delivering prehabilitation prior to TKA. Methods. An observational, retrospective analysis was performed on a consecutive case series of 64 patients who underwent TKA by a single surgeon over a 21-month period. Pre operative Knee Osteoarthritis Outcome Score (KOOS) Patient Reported Outcome Measures (PROMs) were collected on all patients. The first group of patients (control) did not undergo prehabilitation, the subsequent group of patients (experimental) were offered prehabilitation through a mobile application called PhysiTrack. The experimental group were provided with progressive quadriceps and hamstring strengthening exercises, and calf and hamstring stretches. Exercises were automatically progressed after 2 weeks unless the patient requested otherwise or a physiotherapist clinically intervened. The non-compliance rate was 33% (n=11), after removing these patients from the analysis, 22 patients remained and these were age matched to 22 patients from the control group. Aside from the access to prehabilitation, all patients underwent TKA using identical surgical technique and peri-operative care regime. Length of stay data for inpatient care and rehabilitation were captured for all patients. Cost was calculated using the inpatient and rehabilitation costs provided by the hospital. Results. 44 patients were included in our final analysis. Pre operative KOOS were collected for all of the experimental group and 18 (81%) of control group. These subscores were not statistically different (p>0.05) reflecting pre operative equivalence. The average inpatient length of stay was statistically different, being 5.04 days for the control group and 4.31 days for the experimental group (p=0.01). The decision for ongoing inpatient rehabilitation (after the immediate post-operative inpatient period) was not statistically different between the groups (chi-quared p=0.07). Rehabilitation length of stay was 9.12 days in the experimental and 10.85 days in the control group (p = 0.25). The remaining outcomes were statistically significant with total length of stay 11.95 days in the control and 7.63 days in the experimental group (p=0.01) and the total cost of the hospital stay $6362.55AUD for the control and $4145.17AUD for the experimental group (p=0.01). This represents an average saving $2217.38 per patient who participated in prehabiliation prior to surgery. Conclusions. Our research shows a significant cost saving with this intervention, as measured by reduction in total length of stay in patients undergoing prehabilitation using PhysiTrack. To our knowledge, this is the first study that analyses the impact of a mobile application providing prehabilitation prior to TKA. Further work is required to determine the effect in a larger, randomised cohort of patients. Future studies should also be directed towards assessing the utility of digital prehabilitation on a per patient basis prior to total knee arthroplasty

Objectives. Aged trauma patients are at high risk for various comorbidities and loss of function following hip fracture. Consequently a multidisciplinary approach for the treatment of these patients has become more famous in order to maintain the patients” activity level and health status prior to trauma. This study evaluates the effect of a multidisciplinary inpatient rehabilitation on the short- and long-term functional status of geriatric patients following hip fracture surgery. Methods. A collective of 158 hip fracture patients (> 80 years) who underwent surgery were included in this study. An initial Barthel Index lower than 30 points was a criteria to exclude patients from this study. Two subgroups, depending on the availability of treatment spots at the rehabilitation center were made. No other item was used to discriminated between the groups. Group A (n=95) stayed an average of 21 days at an inpatient rehabilitation center specialized in geriatric patients. Group B (n=63) underwent the standard postoperative treatment. As main outcome parameter we used the Barthel Index, which was evaluated for every patient on the day of discharge and checkups after three, six and twelve months. Results. After three months, the average Barthel Index was 82,27 points for group A and 74,68 points for group B (p=0,015). In the six-months-checkup group A”s average Barthel Index was 84,05 points and group B”s was 74,76 points (p=0,004). After twelve months, patients from group A had an average Barthel Index of 81,05 while patients from group B had an average Barthel Index of 71,51 (p=0,010). Conclusion. This study reveals a significant better outcome in both, the short-term and the long-term functional status for geriatric hip-fracture patients, who underwent an inpatient treatment in a rehabilitation center following the initial surgical therapy. This is shown at the timepoints three, six and twelve month after discharge. To maintain quality of life and mobility as well as the patient”s independence in daily life, a treatment in a rehabilitation center specialized in geriatric patients is highly recommendable

Purpose. To update recent findings about the relationship between obesity and post-operative outcome including acetabular cup positioning, complications, readmissions and revision rates, and also inpatient rehabilitation outcome following total hip arthroplasty. Methods. A literature review was done using standard keyword search. Articles were scrutinized by the investigators to ensure relevancy to the purpose of this review. Summary of the review. As the number of all obese(body mass index(BMI) >30) are rising, the development of hip osteoarthritis and the need for total hip arthroplasty(THA) increased. Recent studies found that high BMI was the most significant risk factor contributed to acetabular cup malpositioning following THA. Obesity was found to be a predicting factor for 30-day readmission due to complications include wound infections and thromboembolism after THA. A meta-analysis had shown increased rates of aseptic loosening, dislocation and infection in obese patients thus resulted in higher revision rates compared to nonobese patients but the increase was not found to be statistically significant. Obese patients can make functional improvements during inpatient rehabilitation but at slow progress and higher cost. Conclusion. Based on the current literature, obesity may have a negative impact on the outcome of THA. It appeared that as BMI increases, obesity was related with the risk of postoperative complications, and affected outcomes after total hip arthroplasty. Therefore, this needs to be informed to every patient prior to considering total hip arthroplasty

The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document. Background. The Bundled Payments for Care Improvement (BPCI) initiative was introduced to reduce healthcare costs while maintaining quality. We examined data from a healthcare system comprised of five hospitals that elected to participate in the BPCI Major Joint Replacement of the Lower Extremity Model 2 initiative beginning July 1, 2015. We compared one hospital that did 439 BPCI hip cases to the four other hospitals that did 459 cases. Stratifying the data by hospital volume, we sought to determine if costs decreased during the BPCI period, how the savings were achieved, and if savings resulted in financial rewards for participation. Methods. The Medicare data included the target cost for each episode (based on historical data from 2009–2012 for each hospital that was adjusted quarterly) and actual Part A and Part B spending for 90 days. Using 1,574 primary hip replacements, we analyzed the costs associated with the anchor hospitalization, inpatient rehabilitation, skilled nursing facilities, home health, outpatient physical therapy and readmission to compare the 898 hips done during the 16-month BPCI initiative period with the 676 hips done during the 1-year period preceding BPCI participation. Owing to the nonparametric distribution of the cost data, a Mann-Whitney U test was used to compare the higher volume hospital with the four lower volume hospitals. Results. Compared to the preceding year, the mean episode of care cost during BPCI participation decreased by 14.1% (from $21,823 to $18,755, p=0.02) at the higher volume hospital and by 13.1% (from $32,138 to $27,940, p=0.02) at the lower volume hospitals. During the BPCI period, the mean Medicare target cost was $18,490 at the higher volume hospital and $25,021 at the lower volume hospitals (p<0.001). At the higher volume hospital, the major components of the savings included $526,028 from reduced readmission rates (11.5% versus 3.0%, p<0.001), $393,757 primarily due to reduced length of stay at skilled nursing facilities (mean 33 days versus 26 days, p=0.07), and $205,459 associated with a decreased percentage of patients using inpatient rehabilitation (6.6% versus 3.2%, p=0.03). At the lower volume hospitals, the major components of the savings included $1,002,447 associated with a reduction in the length of stay at skilled nursing facilities (mean 37 days versus 27 days, p<0.001), $487,356 associated with a decrease in the percentage of patients using inpatient rehab (11.6% versus 6.5%, p=0.01), and $355,695 associated with reduced readmission costs. Despite the savings, the mean reconciliation penalty was $184 per case at the higher volume hospital and $2,309 per case at the lower volume hospitals. Stratified by the type of hip replacement, reconciliation for elective primaries resulted in a mean reward of $848 per case for the 409 hips performed at the higher volume hospital and $2,497 per case for the 266 hips done at the lower volume hospitals. For hip fracture cases, reconciliation resulted in a mean penalty of $14,248 per case among the 30 hips done at the higher volume hospital and $8,932 per case for the 193 hips done at the lower volume hospitals. Conclusions. Based on the reduction in costs and decreased readmission rates, the BPCI initiative is achieving its objectives. Although the higher and lower volume hospitals achieved savings during BPCI participation, the target costs were lower than the actual costs resulting in a reconciliation penalty that was driven by the cost of hip fractures. The reconciliation rewards associated with elective primary THAs compared to the substantial penalties associated with hip fractures support the premise that these groups should have different targets costs

BACKGROUND. This study aims to identify recent trends in discharge disposition following bilateral total knee arthroplasty (TKA) as well as factors that predispose patients to enter inpatient rehabilitation facilities (IRF) or skilled nursing facilities (SNF) versus home-rehabilitation (HR). The goal was to identify risk factors that predispose prolonged hospital stays and identify changes in management over time that may be responsible for decreased length of stay (LOS) and a HR program. METHODS. A retrospective cohort study design was used to collect and analyze clinical and demographic data for 404 consecutive bilateral primary total knee arthroplasty (TKA) procedures. Patients who underwent elective primary bilateral total knee arthroplasty from 2011 to 2016 were identified from hospital records at a single institution. Clinical and demographic data including sex, age, and disposition were analyzed. RESULTS. 404 bilateral TKAs were performed by 17 surgeons at a single institution from 2011 to 2016. The average age for bilateral TKA was 63y (31.4–86.6) and 59% were females (239/404). From 2011 to 2016, an increase of 61% (10% to 71%) was noted with regards to home discharge (22.035, <0.001), as well as an increase in the ratio of males being discharged home vs IRF/SNF (1.04 vs 2.4; 2.304, 0.008). Univariate analysis for factors associated with home discharge showed significance for age <60y (3.781, <0.001), age >70 (0.118, 0.001), the use of TXA (3.52, <0.001), type of implant (6.055, <0.001), low postoperative Hg (0.333, <0.001), and yearly trend (Pearson: 0.322, <0.001). Factors associated with prolonged LOS included age <60y (0.641, 0.029), age >70 (1.723, 0.032), active cancer (0.256, 0.027), low postoperative Hg (1.674, 0.020), and postoperative transfusion (1.667, 0.015). Multivariate regression for factors associated with a home discharge showed aggregate significance for BMI <25 (0.886, 0.024), use of TXA (1.139, <0.001), type of implant (1.310, 0.008), age <60 (0.956, 0.004), and age >70 (−1.627, 0.036). Multivariate logistic regression for factors associated with a prolonged LOS showed aggregate significance for active cancer (−1.654, 0.015), postoperative transfusion (0.485, 0.023), and age >70 (0.600, 0.024). CONCLUSION. There has been a significant trend towards postoperative home-rehabilitation programs rather than inpatient rehabilitation following bilateral total knee arthroplasty. There has also been a trend towards an increasing age for those undergoing bilateral total knee arthroplasty. Factors predisposing patients towards non-home discharge disposition include increased age and female gender. The increased use of both TXA and patient specific implants has led to a decrease in operative time and postoperative transfusion rates, and thus a decrease in the overall length of inpatient hospital stay

Introduction. Previous studies on Medicare populations have shown improved outcomes and decreased 90-day episode-of-care costs with robotic assisted total knee arthroplasty (rTKA). The purpose of this study was to evaluate the expenditures and utilization following rTKA in the under 65 y/o population. Methods. TKA procedures were identified using the OptumInsights Inc. database. A two-year window was studied. The procedures were stratified in two groups: the rTKA or manual (mTKA) cohorts. Propensity score matching (PSM) was performed at 1:5. Utilization and associated costs were analyzed for 90 days following the index procedure. 357 rTKA and 1785 mTKA were included in this analysis. Results. Within the 90 days following the surgery, patients who had robotic assisted procedures were less likely to utilize inpatient services (2.24 vs. 4.37%; p=0.0444) and skilled nursing visits (SNF) (1.68 vs. 6.05%; p<0.0001). No patients in the robotic TKA group went to inpatient rehab while 0.90% of the manual cases went to an inpatient rehabilitation facility. Patients who utilized a home health aide in the rTKA arm utilized significantly fewer days of home health (5.33 vs. 6.36 days; p=0.0037). Cost associated with the utilization of these services was lower in the rTKA arm; the overall post-surgery expenditures were $1,332 less in the rTKA arm ($6,857 vs. $8,189; p=0.0018). The 90-day global expenditures (index plus post-surgery) were $4,049 less in the rTKA arm ($28,204 vs. $32,253; p<0.0001). Lastly, length of stay (LOS) after surgery was nearly a day less for the rTKA arm (1.80 vs. 2.72 days; p<0.0001). Conclusion. Robotic assisted TKA was associated with shorter LOS, reduced utilization of services and reduced 90-day payer costs when compared to the manual TKA. For figures, tables, or references, please contact authors directly

Introduction. The purpose of bundled payment programs is to reduce cost via risk sharing, while still maintaining quality. If savings are achieved under a historic target price, the orthopedic surgeon will receive a monetary bonus. If costs are higher, a portion is deducted from payment to the orthopedic surgeon. The purpose of this study was to evaluate our experience with the Bundled Payments for Care Improvement Program (BPCI) when run by an orthopedic surgeon group to determine patient safety and who benefited the most financially. Methods. This program ran from January 2015 through September 2018. 3,186 Medicare total hip and knee replacements, elective (DRG 470) and for fracture (DRG 469), performed by our group were included. 90 day hospital and all postoperative expenditures were reconciled against our historic cost. All patients were medically optimized with discharge plans established preoperatively. We developed preferred skilled nursing facilities and home health care agencies with synergistic medical providers so that discharges were recommended as soon as appropriate. We hired two full-time case managers to have direct contact with patients pre-and post-operatively. Waiver assistance such as house and pet sitters were used if necessary at our expense. 35% of savings went to the convener, who acted as a liaison between our group and CMS. Expenditures for the 90-day period for all patients were calculated to determine where savings occurred and which entity benefitted financially. Results. There was an average 9.2% reduction in hospital readmissions. An estimated total savings of $5,100,000 occurred. There was a 17% reduction in hospital costs, a 12.1% reduction in admissions to skilled nursing facilities with a 34% reduction in length of stay, and a 5% reduction in admissions to inpatient rehabilitation facilities. There was a 35% reduction in home health visits, but no change in outpatient physical therapy visits. After group expenses, final bonus to the orthopedic provider was on average $262 per patient. Conclusion. The physician managed program was very successful from Medicare's standpoint, achieving significant monetary savings without reducing quality of care. However, the bonus to the providing and managing physicians was nominal. It also does not take into consideration the 50 plus hours spent in meetings to develop this program. Participation could be considered a defensive posture so as not to lose more reimbursement. However, experience was gained which will be valuable for future gain sharing programs. Physicians and physician organizations need to sit at the head of the table to manage future payment bundles and perhaps also act as the convener. We deserve this, as a result of demonstrating high safety and cost savings. For figures, tables, or references, please contact authors directly

Introduction. Inpatient rehabilitation services following joint replacement have been estimated to cost over $3 billion/ yr. A shift in reimbursement strategies to bundle payments with the goal of decreasing cost and improving quality has given discharge disposition after joint replacement a front row seat. Our objectives were (1) to establish a correlation between the accuracy of current tools utilized to predict discharge location and (2) compare preoperative and postoperative patient oriented outcomes (POO's) according to discharge disposition. Methods. 188 consecutive total hip arthroplasty (THA) surgeries performed by a single surgeon were prospectively studied. Pre-intervention assessment of the probable and preferred discharge disposition was performed using one of 5 tools (1) experienced surgical coordinator evaluation (2) Risk Assessment and Prediction Tool (RAPT); (3) Charlson Score; (4) ASA Score; and (5) Patient Self-Reported Health Status. Demographic characteristics, Visual Analogue Scale, QWB-7, SF-36, WOMAC, clinical scores were recorded before and after surgery. Correlation between final discharge disposition (home vs rehab) and its predictors was performed. Preoperative and postoperative outcomes were compared, p<0.05 was considered significant. Results. Most accurate predictor of discharge disposition was determined by our experienced surgical coordinator (OR: 11.05; 95% CI of 2.21 to 55.32; p<0.001), followed by the RAPT (OR: 1.56; 95% CI of 1.29 to 1.90; p=0.01). We found a significant difference in age (Rehab: 72.4 SE 1.2 vs Home: 70.3 SE 1.0; p=0.01) and length of stay (Rehab: 3.6 SE 0.01 vs Home: 3.14 SE 0.07; p<0.001) between those discharged to rehab than those discharged home. Mean follow-up time was 2.22 years (range 1–4 years). There was a significant difference between groups on most outcome measures preoperatively (rehab worse than home; p<0.001). Both groups demonstrated significant improvement in all patient perceived outcome measures after THA, but those discharged to rehab continue to report worse scores for the QWB (Rehab: 0.62 SE 0.02 vs Home: 0.67 SE 0.01; p=0.02) and Hip Harris Score (Rehab: 83.07 SE 1.75 vs Home: 88.65 SE 1.31; p=0.01). Discussion. Clinical intuition and personal interaction proved to be the best predictor for discharge disposition. Worse outcomes were observed in patients being discharged to rehab. For any tables or figures, please contact the authors directly

Introduction. Patient demand for hip and knee arthroplasty continues to rise. Information sources providing data on the volume and cost of Medicare total joint arthroplasty by hospital are of use to patients and healthcare professionals. Data have demonstrated that higher volume surgeons are associated with lower cost, morbidity, and mortality. The current study assesses if the same is true for hospitals. Methods. The Limited Data Set (LDS) from the Centers for Medicare and Medicaid (CMS) were used for this study. All elective, DRG 470 Total Hip Arthroplasties (THA) reported by CMS from the first quarter of 2013 through the second quarter of 2016 were included. Volume and part A Medicare payments over a 90-day period for the 20 highest volume hospitals in the US were analyzed. Cost associated with initial hospital stay and post discharge skilled nursing, home health, long term acute care, inpatient rehabilitation facilities, and readmission was aggregated and analyzed. For each episode, demographic information (age, sex, and race), geographic location, and Elixhauser comorbidities were calculated to control for major confounding factors in the regression. Results. For the 20 highest volume centers in the US, total joint volume for CMS insured patients varied from 1104 to 5069. Average cost varied from $16,974 to $22,094. For the 20 highest volume cities in the US, total joint volume for CMS insured patients varied from 1,501 to 6,727. Average Medicare part A payment varied from $14,255 to $21,125. Readmission % varied from 3.9% to 8.2%. 90-day mortality varied from 0.0% to 0.57%. DISCUSSION AND CONCLUSION. The variation in volume between the top 20 centers in the US varies by more than a factor of 4 with the highest volume hospital having almost twice the volume as the second highest hospital. Part A payments, readmissions, and mortality also varied widely. Within the top 20 hospitals by volume, there does not appear to be a correlation between volume and cost

To examine the impact of a structured rehabilitation programme as part of an integrated multidisciplinary treatment algorithm for adult spinal deformity patients. A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for sagittal malalignment were included (n=32). Details of physiotherapy initial evaluation, inpatient rehabilitation progress, details of bracing treatment and time to discharge were collected. Clinical outcome scores were measured preoperatively and at 6 weeks, 6 months and 1 year postoperatively. After second stage corrective surgery, the mean time to standing without assistance was 2.1 days, mean time to independent ambulation was 4.2 days, mean time to competent ascending and descending stairs was 5.6 days and mean time to moulded orthosis application 7.1 days. Successful progression through the structured rehabilitation programme was associated with high clinical outcome scores and improved health related quality of life (HRQOL). The introduction of this programme contributed to the development of an enhanced recovery pathway for patients having adult spinal deformity surgery, reducing inpatient length of stay and optimising clinical outcomes

Objectives. The goal of this study was to describe and evaluate the implementation of a tailored care pathway as an alternative to a standard joint care protocol in the postoperative in-hospital rehabilitation after total knee replacement (TKR) on clinically relevant outcome parameters. Methods. We monitored an orthopaedic department regarding postoperative rehabilitation after TKR on several outcome parameters throughout a period of 32 months, whilst introducing a new care pathway after 17 months. Outcome parameters were monitored and comprised: Time to get functionally recovered (in days), length of stay (in days) and destination of discharge. Key-differences between the joint care protocol and the new tailored pathway were: 1. determination of individual short term rehabilitation goals on the basis of a preoperative clinical prediction rule and postoperative monitoring of functional recovery, 2. Enhancement of expertise of and collaboration between health care professionals and 3. implementation of fast track rehabilitation. We compared the patients operated after implementation of the tailored care pathway with those who were treated according to the joint care protocol. Regression analysis was used to estimate differences between the two groups of patients while correcting for baseline differences in risk profile between the groups. Results. Introduction of the tailored care pathway decreased the length of stay on average from 5.2 days to 4.2 days, (p< 0.01). In addition, there was a 7% non-statistically significant reduction in the number of patients who required inpatient rehabilitation after hospital discharge. Conclusion. Introduction of the tailored care pathway reduced the mean length of stay by one day, whilst patient safety and satisfaction remained unaltered

Purpose: To examine the outcome of primary and revision knee arthroplasty in very elderly patients. Methods and Results: Patients in their 90th year of life who underwent primary or revision knee arthroplasty between January 2000 and September 2007 were identified. Data was collected regarding demographics, ASA grade, co-morbid factors, complications, length of inpatient stay, the need for transfusion and discharge destination. Thirty day, 1 year and current mortality figures were calculated. Twenty one procedures were performed on 18 patients with a mean follow up of 18.8 months (3–57.9). There were 14 primary total knee replacements and 7 revision procedures. The mean age at the time of surgery was 90 years and 10 months (89 years 1 month to 94 years 4 months). The majority of patients were female (15). All patients were ASA grade 2 or 3. The average orthopaedic inpatient stay was 17 days. Thirty percent of patients required a period of further inpatient rehabilitation or convalescence after discharge from our institution. Nine patients experienced a post-operative complication. Mortality at 30 days was 0%, at 1 year 6% (1/16), and is currently 17% (3/18). Conclusion: Very elderly patients are able to tolerate primary and revision knee arthroplasty although there is a high rate of peri-operative complications. We propose that there should be a different tariff for arthroplasty procedures in extremely elderly patients to reflect the increased rate of complications and prolonged postoperative hospital stay

Objective: To report on health care utilization and associated cost for musculoskeletal conditions in Germany. Methods: As part of a Bone and Joint Decade project data were collected from governmental bodies, health insurance companies, pension funds, hospital discharge reports and other sources for the year 2002. Results: According to the hospital discharge reports 17.8 % of all acute hospital days were due to musculoskeletal conditions or injuries, with joint disorders and back problems being the most frequent reasons for admission. 40% of all inpatient rehabilitation treatments were caused by musculoskeletal conditions. In the ambulatory segment, 27% of all patients visited during a 12 month period an orthopaedic surgeon or a rheuma-tologist. In addition, 37% of all GP consultations were due to musculoskeletal complains. These disorders were also responsible for about 40% of all days lost from work and 25% of all early retirements. The overall cost for musculoskeletal conditions in 1999 in Germany was about 40 Billion Euro, with back problems responsible for about 50%, and joint problems for another 30%. Conclusion: Musculoskeletal conditions are the major cause of morbidity in the German society and substantially influence health and quality of life, with enormous cost to health systems. Considering the demographic changes immediate strategies have to be developed to address these problems, to prevent the diseases and to allow for early and appropriate care

Objective: To examine the effectiveness of a specific physiotherapy program before hip arthroplasty in patients with hip osteoarthritis. Design: Multidimentional prospective randomised controlled study. Subjects: 25 patients meet the inclusion criteria and were randomised in a study and a control group. Intervention: All the patient underwent THA performed by the same surgeon and implanted with the same prosthesis. Study group performed educational and physiotherapy program one month before surgery. Study and control group performed inpatient rehabilitation program only post surgery. Main outcome measures: patients were evaluated, 1 month before surgery(T0), the day before surgery (T1), 15 days (T2), at 4 weeks (T3) and at 3 months (T4) post surgery using measure of hip muscle strength, hip range of motion, Barthel Index, Short Form-36, WOMAC, Harris Hip Score (HHS), Visual Analogue Scale (VAS). Results: The study group present significant improvement of hip extrarotation at each evaluation, significant high values of gluteus medius strength (p level 0,004) at T1, significant hip abduction (p level 0,02) at T3, significant lower score in VAS at T1 (p level −2,10), T3 (p level −2,10) and at T4 (p level 0,02), significant improvement in Womac scores (p level −2,32) at T4. In study group, SF 36 Physical composite score was significant high at T1(p level 0,048), Mental composite score at T2 (p level 0,006) and T3 (p level 0,02). Conclusion: our pre surgery programme improves values of clinical status and social function, besides pain reduced before surgery until three months after surgery