Total Knee Replacement: The Inpatient-Only List and the Two Midnight Rule, Patient Impact, Length of Stay, Compliance Solutions, Audits, and Economic Consequences

Iorio, Richard; Barnes, C. Lowry; Vitale, Matthew P.; Huddleston, James I.; Haas, Derek A.

doi:10.1016/j.arth.2020.01.007

Cited by 33 publications

(25 citation statements)

References 3 publications

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“…Multiple injections are often necessary at each treatment cycle, and it must generally be repeated every six months [ 12 ]. There has been no effective non-surgical treatment, so total knee arthroplasty (TKA) is now performed extensively for OA, but is associated with substantial cost and morbidity [ 12 , 13 , 14 , 15 , 16 ]. The incidence of TKA has increased dramatically in recent years, and is now commonly performed for even mild and moderate arthrosis [ 14 , 17 , 18 ].…”

Section: Introductionmentioning

confidence: 99%

Autologous Biologic Treatment with Fat, Bone Marrow Aspirate and Platelet Rich Plasma Is an Effective Alternative to Total Knee Arthroplasty for Patients with Moderate Knee Arthrosis

Prodromos

Finkle

2020

Medicines

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Background: Osteoarthrosis (OA) of the knee afflicts millions worldwide. Total Knee Arthroplasty (TKA) is common, but associated with substantial cost and morbidity. Prior studies of intra-articular injection of fat, bone marrow aspirate (BMA), and platelet rich plasma (PRP) have shown clinical benefit. We hypothesized that injection of autologous adipose tissue, BMA, and PRP would provide significant benefit for patients with moderate knee OA resulting in avoidance of total knee arthroplasty (TKA) in most, with discontinuance of NSAIDs and other drugs. Methods: 42 TKA candidate patients (47 knees) with moderate (Kellgren-Lawrence 2 and 3) knee OA who had failed conservative treatment had autologous adipose tissue, BMA, and PRP injection as an alternative to TKA in office using only local anesthetic. Patients had discontinuance of all nonsteroidal anti-inflammatory medicines (NSAIDs) and other analgesics, except acetaminophen, prior to treatment. Patients were evaluated with Knee injury and Osteoarthritis Outcome Score Physical Shortform (KOOS-PS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Single Assessment Numeric Evaluation (SANE) prior to treatment, and at 6 months, 1, and 2 years after treatment. Results: Follow up exceeded 80% at all time points. There were no significant adverse events. TKA was avoided in 97% at one and 86% at two years after treatment. Mean SANE, KOOS-PS, and WOMAC scores significantly improved at 6 months, 1, and 2 years post-treatment. WOMAC and SANE scores were higher at two versus one year post-treatment. Conclusions: Combined fat, BMA, and PRP injection is a safe and effective treatment for moderate knee OA, with reliable avoidance of TKA and possible continued improvement at two year follow-up.

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Section: Introductionmentioning

confidence: 99%

Autologous Biologic Treatment with Fat, Bone Marrow Aspirate and Platelet Rich Plasma Is an Effective Alternative to Total Knee Arthroplasty for Patients with Moderate Knee Arthrosis

Prodromos

Finkle

2020

Medicines

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“…CMS maintains that there is no expectation for all TKA procedures to be performed in the outpatient/ASC setting and that status determination is a complex medical decision that remains in the purview of the orthopedic surgeon [10]. Retaining the decisionmaking power places increased burden on the physician for documentation to support the level of necessary postoperative care.…”

Section: Practical Implicationsmentioning

confidence: 99%

Total Knee Arthroplasty in Ambulatory Surgery Centers: The New Reality!

2020

Self Cite

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By streamlining surgical care and eliminating postoperative hospitalization, the transition to ambulatory total knee arthroplasty (TKA) has the potential to improve efficiency and minimize the costs of care. However, practical, legal, and financial implications remain to be addressed. The Centers for Medicare and Medicaid Services has also yet to address concerns generated by the removal of TKA from the Inpatient-Only List and provide guidance on patient selection. Rolling out regulatory changes that impact highvolume procedures, such as TKA, in a short period of time and without appropriate feedback can only lead to further confusion. As surgeons, we are in a unique business model that requires us to constantly innovate to deliver high quality care, while also taking financial cuts as a result of our innovations.

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“…The Center for Medicare and Medicaid services (CMS) seeks to further lower costs, by removing TJA from the inpatient-only list [8e17]. CMS has removed total knee arthroplasty (TKA) from the inpatient-only list in 2018, and THA in January 2020 [11,12]. CMS defines an inpatient stay when the patient spends 2 midnights at Availability: The trained XGBoost model and data processing code are available upon request from the authors.…”

Section: Introductionmentioning

confidence: 99%

“…Therefore, many argue that Medicare beneficiaries can undergo THA at an ambulatory center or in the outpatient hospital setting, which will subsequently result in substantial savings for the CMS [9]. However, many Medicare patients, especially the elderly and those with more comorbidities and decreased preoperative functional status, require an inpatient admission after TJA [5,9,12,13,17]. Therefore, with THA taken off the inpatient-only list, providers and hospitals have added pressure in classifying most THAs as an outpatient procedure, subsequently resulting in increased costs for physicians and health-care systems.…”

Section: Introductionmentioning

confidence: 99%

“…Therefore, with THA taken off the inpatient-only list, providers and hospitals have added pressure in classifying most THAs as an outpatient procedure, subsequently resulting in increased costs for physicians and health-care systems. Ultimately, this may beget a bias in care toward the elderly and frail patients, who are more likely to require an inpatient admission after TJA [5,6,9,10,12,13].…”

Section: Introductionmentioning

confidence: 99%

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A Novel Machine Learning Predictive Tool Assessing Outpatient or Inpatient Designation for Medicare Patients Undergoing Total Hip Arthroplasty

et al. 2021

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Background: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list. This has created significant confusion regarding which patients qualify for an inpatient designation. The purpose of this study is to develop and validate a novel predictive tool for preoperatively objectively determining "outpatient" vs "inpatient" status for THA in the Medicare population. Methods: A cohort of Medicare patients undergoing primary THA between January 2017 and September 2019 was retrospectively reviewed. A machine learning model was trained using 80% of the THA patients, and the remaining 20% was used for testing the model performance in terms of accuracy and the average area under the receiver operating characteristic curve. Feature importance was obtained for each feature used in the model. Results: One thousand ninety-one patients had outpatient stays, and 318 qualified for inpatient designation. Significant associations were demonstrated between inpatient designations and the following: higher BMI, increased patient age, better preoperative functional scores, higher American Society of Anesthesiologist Physical Status Classification, higher Modified Frailty Index, higher Charlson Comorbidity Index, female gender, and numerous comorbidities. The XGBoost model for predicting an inpatient or outpatient stay was 78.7% accurate with the area under the receiver operating characteristic curve to be 81.5%. Conclusions: Using readily available key baseline characteristics, functional scores and comorbidities, this machine-learning model accurately predicts an "outpatient" or "inpatient" stay after THA in the Medicare population. BMI, age, functional scores, and American Society of Anesthesiologist Physical Status Classification had the highest influence on this predictive model.

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Total Knee Replacement: The Inpatient-Only List and the Two Midnight Rule, Patient Impact, Length of Stay, Compliance Solutions, Audits, and Economic Consequences

Cited by 33 publications

References 3 publications

Autologous Biologic Treatment with Fat, Bone Marrow Aspirate and Platelet Rich Plasma Is an Effective Alternative to Total Knee Arthroplasty for Patients with Moderate Knee Arthrosis

Autologous Biologic Treatment with Fat, Bone Marrow Aspirate and Platelet Rich Plasma Is an Effective Alternative to Total Knee Arthroplasty for Patients with Moderate Knee Arthrosis

Total Knee Arthroplasty in Ambulatory Surgery Centers: The New Reality!

A Novel Machine Learning Predictive Tool Assessing Outpatient or Inpatient Designation for Medicare Patients Undergoing Total Hip Arthroplasty

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