Study Examines Effects of CMS’ Two-midnight Rule in TJA
A study published in the January issue of The Journal of Arthroplasty assessed how the application of the Centers for Medicare & Medicaid Services’ (CMS) two-midnight rule (TMR) to short-stay (one-midnight) inpatient hospitalizations (SSIH) affected clinical and financial outcomes in total joint arthroplasty (TJA). National Inpatient Sample data from 2012 through 2016 were collected to evaluate length of stay trends after elective TJA. Three scenarios were assessed for all 2016 Medicare SSIHs: (1) all patients kept an extra midnight to satisfy the TMR; (2) all patients discharged as an outpatient; and (3) all patients discharged as an inpatient. The rate of Medicare SSIHs rose from 2.7 percent in 2012 to 17.8 percent in 2016. In scenario one, no changes were observed in CMS payments, and hospitals lost $117 million. In scenario two, payments from CMS were reduced by $181.8 million, and hospitals lost $357.3 million. In scenario three, CMS payments did not change, and about $1.71 billion of SSIH charges were at risk to hospitals for audit. In all three scenarios, patient out-of-pocket costs did not change.
A systematic review published in the February issue of the Journal of Shoulder and Elbow Surgery evaluated characteristics of and treatments for periprosthetic joint infection (PJI) following total elbow arthroplasty (TEA). The PubMed and Scopus databases were queried in December 2018 using key words, including “elbow replacement infection” and “elbow arthroplasty infection.” Of 1,056 titles identified, 15 were included in the final analysis, encompassing 309 TEA-related infections. The two most frequent isolated organisms were Staphylococcus aureus (42.4 percent) and coagulase-negative staphylococci (32.6 percent). Elbow PJI risk factors included rheumatoid arthritis, steroid use, an immunocompromised state, and prior elbow surgery. The most successful technique for eliminating the infection was two-stage revision (81.2 percent) and the least successful was with irrigation and débridement for component retention (55.8 percent).
Study: Which Pediatric Femoral Shaft Fracture Patients Are Most Likely to Require Blood Transfusion?
A retrospective study published online in Injury identified factors associated with blood transfusion in children with pediatric femoral shaft fracture. Operative femoral shaft fracture patients treated between 2004 and 2017 at a tertiary pediatric hospital were identified. The following data were collected from electronic medical records: fixation method, additional injuries, blood loss (estimated blood loss [EBL], hemoglobin, hematocrit), and transfusion. Patients were stratified based on whether they had additional injuries, defined as additional fractures and/or abdominal, chest, or head injuries. Final analysis included 172 patients: 129 with isolated femoral shaft fractures and 43 with concomitant additional injuries. Patients with isolated femoral shaft fractures had a significantly lower transfusion rate (0.8 percent) than those with additional injuries (39.5 percent). Patients with additional injuries were more likely to require transfusion if they had additional surgeries. In the isolated fracture group, EBL was higher in those who received rigid intramedullary nails compared to flexible intramedullary nails. Transfusion rates and changes in hemoglobin and hematocrit did not differ regardless of fixation method in isolated fracture patients.
Study Explores Clinical Course of Pain and Disability after Lumbar Diskectomy
A meta-analysis published online in the European Spine Journal observed that lumbar diskectomy may be associated with clinically relevant immediate improvement in leg pain and disability. The researchers performed a database search for relevant prospective cohort studies evaluating patients aged older than 16 years who received first-time lumbar diskectomy due to sciatica/radiculopathy, did not have complications, and were followed from the point of surgery. Studies not published in English or that included revision surgery were excluded. Eighty-seven studies encompassing 31,034 total patients were included; 49 studies had a moderate risk bias, and 38 had a high one. The authors observed clinically relevant improvements immediately postoperatively or leg pain and disability; back pain also presented improvements.
CMS Paid $2.6 Billion for Undelivered Postoperative Visits
Undelivered postoperative visits included in procedure bundles cost Medicare about $2.6 billion in 2018, according to a new report. Postoperative visits comprise about 25 percent of Medicare payments to physicians for procedures that include bundled postoperative care, totaling about $9.9 billion in 2017.
AOFAS Uses Its Annual Meeting to Promote Gender Diversity
The lack of gender diversity in orthopaedics may be old news, but an article published in 2018 in The Journal of Bone & Joint Surgery offered a view by specialty society. The data may be sobering to subspecialties, but initiatives undertaken by the American Orthopaedic Foot & Ankle Society (AOFAS) offer a model that other societies and organizations may emulate to engage women and support them in leadership roles. Several events at the most recent AOFAS Annual Meeting were designed to celebrate and connect women in the subspecialty.
