News in 10

The 10 items below are the most significant elements of recent editions of Headline News Now—the AAOS thrice-weekly, online update of news of interest to orthopaedic surgeons. Check this page regularly for updates.
Updated on August 25, 2015

1. Study looks at long-term outcomes for ACL reconstruction using middle-third patellar tendon autograft.
A study published online in The American Journal of Sports Medicine examines long-term outcomes for patients who undergo anterior cruciate ligament (ACL) reconstruction using middle-third patellar tendon autografts. The researchers conducted a longitudinal, prospective study of 90 patients who were evaluated at 1, 2, 3, 4, 5, 7, 10, 15, and 20 years after surgery. At 20-year follow-up, they found that 32 (36 percent) patients had sustained another ACL injury: 8 (9 percent) to the index limb and 27 (30 percent) to the contralateral limb, with three injuring both knees. Overall, 50 percent of patients participated in strenuous or very strenuous activities, and kneeling pain was present in 63 percent. The researchers noted that female patients were less likely to injure the reconstructed ACL, had poorer International Knee Documentation Committee (IKDC) subjective scores, had more activity-related pain, and were less likely to participate in strenuous activities. The researchers found radiographic osteoarthritis in 61 percent of patients, but noted that symptomatic osteoarthritic symptoms were rarely reported.
Read the abstract…

2. Report: Negotiating drug prices could save Medicare up to $16 billion per year.
A report released jointly by Carleton University School of Public Policy and Administration and the consumer group Public Citizen argues that Medicare Part D could save between $15.2 billion and $16 billion each year if it could secure the same prices that Medicaid or the Veterans Benefits Administration (VBA) receives on the same brand-name drugs. Additional findings from the report include:

  • After rebates, brand-name drugs cost Medicare Part D 198 percent of the median costs for the same brand-name drugs in the 31 Organization for Economic Cooperation and Development (OECD) countries.
  • Medicare Part D pays, on average, 73 percent more than Medicaid and 80 percent more than the Veterans Benefits Administration (VBA) for brand-name drugs.
  • Although Medicaid and VBA often are used as benchmarks, those organizations also pay higher prices than many OECD countries.
    Read the report (PDF)…

3. CMS projects healthcare spending to grow 5.8 percent per year.

The U.S. Centers for Medicare & Medicaid Services (CMS) has released a report that projects total healthcare spending to increase an average of 5.8 percent per year during the period 2014 through 2024. The authors note that the rate is less than the 9 percent average seen in the three decades leading up to 2008. Other findings of the report include the following:

  • Approximately 19.1 million additional people are expected to enroll in Medicare during the next 11 years as more members of the so-called "baby boom generation" become eligible.
  • The overall insured rate is expected to rise from 86.0 percent to 92.4 percent over the next 11 years.
  • Medicaid spending during 2014 is projected to have decreased by 0.8 percent because new enrollees are expected to be somewhat healthier than those who were enrolled previously. Overall spending, however, is projected to have increased by 12.0 percent in 2014, as a result of a 12.9 percent increase in enrollment related to coverage expansion under the Affordable Care Act.

    View the abstract…

    View the complete report…

4. Study: HACs may be strongest predictor of readmission after primary hip or knee arthroplasty.
Hospital-acquired conditions (HACs) were the strongest predictor of readmission after primary hip or knee arthroplasty, according to a study published in the August issue of The Journal of Arthroplasty. The authors attempted to identify risk factors for readmission after hip and knee arthroplasty, using national Veteran’s Administration data on 26,710 total and partial primary arthroplasty procedures (16,808 knees and 9,902 hips) across 96 hospitals between 2005 and 2009. The retrospective cohort study found the overall 30-day readmission rate to be 7.3 percent (n = 1940), with readmission rates of 8.4 percent for hip arthroplasty and 6.6 percent for knee arthroplasty. HACs accounted for 42 percent of all complications. Among HACs, urinary tract infections were the most common, followed by surgical site infections, venous thromboembolism, and pneumonia.
Read the abstract…

5. Study: Standards for blood clot prevention after surgery may be set too low.
A research letter published online in the journal JAMA Surgery argues that "best-practice" standards for the prevention of blood clots after surgery may be set too low. The researchers conducted a retrospective review of 128 patients treated at a single center, all of who developed hospital-acquired venous thromboembolism (VTE) and were flagged by the Maryland Hospital Acquired Conditions pay-for-performance program. They found that 36 patients (28 percent) had non-preventable, catheter-related upper extremity clots, leaving 92 patients (72 percent) with potentially preventable clots. Of those patients, 79 (86 percent) were prescribed clot-preventing medications, yet only 43 (47 percent) received "defect-free care." Of the 49 patients (53 percent) who received suboptimal care, 13 (27 percent) were not prescribed risk-appropriate clot-preventing drugs, and 36 (73 percent) missed at least one dose of appropriately prescribed medication. The researchers note that existing VTE care goals set by The Joint Commission and CMS say that one dose of clot-preventing medication is given to patients within the first day of hospitalization, but data suggest that may not be enough.

6. IOM report addresses wait times and timeliness of care.
A report released by the Institute of Medicine looks at timeliness in access to health care. The authors note that delays can negatively affect health outcomes, patient satisfaction, healthcare utilization, and organizational reputation. They offer the following basic principles to develop systems-based approaches to scheduling and access that provide immediate engagement of a patient’s concern at the point of initial contact:

  • Matching supply with projected demand through formal, ongoing evaluation
  • Immediate engagement and exploration of patient’s needs, at the time of inquiry
  • Patient preference on the timing and nature of care, invited at inquiry
  • Need-tailored care with reliable, acceptable alternatives to clinician visits
  • Surge contingencies, or provisions for accommodating patients’ acute issues that cannot be addressed in a timely manner
  • Continuous assessment of changing circumstances in each care setting
  • The writers argue that professional societies and organizations should work with standards and certification organizations to assess and improve scheduling and access.
    Read more, with related links…

7. CMS states that more than 2,100 facilities have agreed to assume financial risk for episodes of care.
CMS has announced that more than 2,100 acute care hospitals, skilled nursing facilities, physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies have transitioned from a preparatory period to a risk-bearing implementation period in which they assume financial risk for episodes of care. The participants include 360 organizations that have entered into agreements with CMS to participate in the Bundled Payments for Care Improvement initiative, and an additional 1,755 providers who have partnered with those organizations. This is a separate initiative from the recently announced Comprehensive Care for Joint Replacement Model, although both are part of a framework established by the Affordable Care Act to shift reimbursement to a quality-of-care model.

8. Study: Use of a comanagement team for patients with osteoporotic hip fractures may reduce costs at moderate- to high-volume hospitals.
According to findings published online in the journal Clinical Orthopaedics and Related Research (CORR), use of a multidisciplinary team that includes orthopaedic surgeons, internal medicine physicians, social workers, and specialized physical therapists may decrease complication rates, improve time to surgery, and reduce hospital length of stay for patients with osteoporotic hip fractures. The researchers conducted an economic analysis to determine whether implementation of a comanagement model of care for geriatric patients with osteoporotic hip fractures would be cost-effective at moderate-volume hospitals (at least 50 cases annually). They found that, for the base case, universal comanagement was more cost-effective than traditional care and risk-stratified comanagement. In addition, comanagement was more cost-effective than traditional management as long as the hip fracture case volume was more than 54 patients annually, and resulted in cost savings when there were more than 318 patients annually.
Read the abstract…

9. Survey projects significant reduction in uninsured since 2013.
According to survey data released by Gallup, the percentage of people in the United States who lack health insurance has fallen from 17.3 percent in full-year 2013 to 11.7 percent in the first half of 2015. The company based its information on a random sample of 178,072 adults in 2013 and 88,667 adults through the first half of 2015. All survey participants were aged 18 years or older, and the survey covered all 50 states and the District of Columbia. In addition, the researchers note that states that opted to expand Medicaid and set up their own state exchanges or partnerships in the health insurance marketplace have seen significantly greater declines in uninsured rates since 2013 compared to states that did not take those steps.

10. Article highlights potential concerns with proposed CCJR payment model.
An article on the Health Affairs blog examines a recently released U.S. Centers for Medicare & Medicaid Services (CMS) proposal to bundle payments and quality measures for hip and knee arthroplasty at hospitals in 75 randomly selected geographic areas. Under the Comprehensive Care for Joint Replacement (CCJR) payment model, the hospital in which the procedure is performed would be accountable for costs associated with the entire episode of care, from the time of surgery through 90 days postoperative. The writer outlines the following areas of concern:

  • The proposal is hospital-centric. Leaving physicians, post-acute care providers, and others out of the program may encourage conflicts instead of collaboration between providers.
  • The model prevents the possibility of using outpatient or other suitable sites of care for such surgeries, possibly promoting increased consolidation in the healthcare industry.
  • The proposal does not vary payments to hospitals based on severity of the patient’s condition.
  • The diagnosis-related groups targeted by the program are broad, and include procedures unrelated to replacing a hip or knee.
  • Provider payments would not be reconciled until the end of the year.

    Learn more about the CCJR payment model…