Download PDF
The Journal of Hip Surgery 2020; 04(02): 066-076
DOI: 10.1055/s-0040-1712520
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Can the Choice of Cementless Implants and Bearings during Total Hip Arthroplasty Have an Impact on the Overall Costs within a Bundled Payment Model?

Stephen Duncan
1   Department of Orthopaedics, University of Kentucky, Lexington, Kentucky
,
Ankur Patel
2   Department of Health Economics, Smith and Nephew Biotherapeutics, Fort Worth, Texas
,
Gary Delhougne
2   Department of Health Economics, Smith and Nephew Biotherapeutics, Fort Worth, Texas
,
Corey Patrick
3   Division of Orthopaedics, Department of Health Economics, Smith and Nephew Inc, Cordova, Tennessee
› Author Affiliations Funding Smith and Nephew (Smith and Nephew Orthopaedics).
Further Information

Publication History

23 November 2019

20 March 2020

Publication Date:
09 June 2020 (online)

    Permissions and Reprints

Abstract

The comprehensive care for joint replacement model from the Center for Medicare and Medicaid Services and similar programs from other payers make hospitals and health care systems more responsible for better clinical and economic outcomes of total hip arthroplasty (THA) patients. The objective of the study was to evaluate hospital-related clinical and economic outcomes of using the cementless R3 cup and Polarstem with an oxidized zirconium bearing compared with other cementless hip systems using a ceramic bearing in THA patients. We retrospectively reviewed primary THA patients from the premier perspective database between 2014 and 2018Q3. Patients with R3 cup and Polarstem with an oxidized zirconium bearing were identified using appropriate keywords from billing records and compared against cementless and ceramic-on-polyethylene (CoP) THA patients who did not meet the keywords' criteria. Patients were excluded if they were < 21 years of age; outpatient hospital discharges; evidence of revision THA; bilateral THA in same discharge or different discharges. 1:3 propensity score matching was used to control patients' demographic, clinical, and hospital characteristics. Generalized estimating equation model with appropriate distribution and link function was used to estimate hospital-related cost while logistic regression models were used to estimate discharged status, transfusion, and 30-days readmission. The study matched 818 R3/Polarstem with oxidized zirconium bearing patients with 2,454 CoP cementless THA patients. Length of stay for the R3/Polarstem patients (mean = 1.61 days; confidence interval [CI] = 1.41–1.80) was significantly lower (p-value ≤ 0.0001) than CoP THA patients (mean = 2.06 days; CI = 1.95–2.17). R3/Polarstem hip patients were 36% (odds ratio [OR] = 1.36; CI = 1.07–1.72; p-value = 0.0112) more likely to be discharged to home/home health care, 18% (OR = 0.82; CI = 0.63–1.06; p-value = 0.1235) less likely to be discharged to a skilled nursing facility (SNF), 84% less likely to have transfusion (OR = 0.16; CI = 0.09–0.29; p-value ≤ 0.0001), and 44% (OR = 0.56; CI = 0.32–0.98; p-value = 0.0412) less likely to readmitted within 30 days than CoP THA patients. Mean total hospital costs was marginally higher for R3/Polarstem patients (mean = $15,611; vs. $15,002; p-value = 0.0041) than CoP THA patients. While the total hospital costs for the R3/Polarstem was higher than CoP, the reduced length of stay, reduced discharge to SNF, and lower readmission rates can help to save money in the bundled payment and make the use of certain cementless hip systems a potential cost saving solution.

Keywords

oxidized zirconium hip implant - length of stay - discharge status - total hospital cost
 

  • References

  • 1 Fingar KR, Stocks C, Weiss AJ, Steiner CA. . Most frequent operating room procedures performed in U.S. hospitals, 2003–2012: Statistical Brief #186. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Healthcare Research and Quality; 2006
  • 2 Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; comprehensive care for joint replacement payment model for acute care hospitals furnishing lower extremity joint replacement services. Final rule. Fed Regist 2015; 80 (226) 73273-73554
    PubMedGoogle Scholar
  • 3 Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 2009; 91 (01) 128-133
    CrossrefPubMedGoogle Scholar
  • 4 Lehil MS, Bozic KJ. Trends in total hip arthroplasty implant utilization in the United States. J Arthroplasty 2014; 29 (10) 1915-1918
    CrossrefPubMedGoogle Scholar
  • 5 Heckmann ND, Sivasundaram L, Stefl MD, Kang HP, Basler ET, Lieberman JR. Total hip arthroplasty bearing surface trends in the United States from 2007 to 2014: the rise of ceramic on polyethylene. J Arthroplasty 2018; 33 (06) 1757-1763.e1
    CrossrefPubMedGoogle Scholar
  • 6 Rames RD, Stambough JB, Pashos GE, Maloney WJ, Martell JM, Clohisy JC. Fifteen-year results of total hip arthroplasty with cobalt-chromium femoral heads on highly cross-linked polyethylene in patients 50 years and less. J Arthroplasty 2019; 34 (06) 1143-1149
    CrossrefPubMedGoogle Scholar
  • 7 Cooper HJ, Urban RM, Wixson RL, Meneghini RM, Jacobs JJ. Adverse local tissue reaction arising from corrosion at the femoral neck-body junction in a dual-taper stem with a cobalt-chromium modular neck. J Bone Joint Surg Am 2013; 95 (10) 865-872
    CrossrefPubMedGoogle Scholar
  • 8 Yoon BH, Park IK. Atraumatic fracture of the BIOLOX delta ceramic liner in well-fixed total hip implants. Orthopedics 2018; 41 (06) e880-e883
    CrossrefPubMedGoogle Scholar
  • 9 Hampton C, Weitzler L, Baral E, Wright TM, Bostrom MPG. Do oxidized zirconium heads decrease tribocorrosion in total hip arthroplasty? A study of retrieved components. Bone Joint J 2019; 101-B (04) 386-389
    CrossrefPubMedGoogle Scholar
  • 10 Assaf A, Manara JR, Teoh KH, Evans AR. Mid-term clinical results of the cementless R3 cup and polar stem total hip arthroplasty. Eur J Orthop Surg Traumatol 2019; 29 (04) 827-833
    CrossrefPubMedGoogle Scholar
  • 11 National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. Annual Report 2018. London, England: National Joint Registry; 2018
    PubMed
  • 12 Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res 2014; 472 (01) 188-193
    CrossrefPubMedGoogle Scholar
  • 13 Kurtz SM, Lau E, Baykal D, Odum SM, Springer BD, Fehring TK. Are ceramic bearings becoming cost-effective for all patients within a 90-day bundled payment period?. J Arthroplasty 2019; 34 (06) 1082-1088
    CrossrefPubMedGoogle Scholar
  • 14 Carnes KJ, Odum SM, Troyer JL, Fehring TK. Cost analysis of ceramic heads in primary total hip arthroplasty. J Bone Joint Surg Am 2016; 98 (21) 1794-1800
    CrossrefPubMedGoogle Scholar
  • 15 Wyles CC, McArthur BA, Wagner ER, Houdek MT, Jimenez-Almonte JH, Trousdale RT. Ceramic femoral heads for all patients? An argument for cost containment in hip surgery. Am J Orthop 2016; 45 (06) E362-E366
    PubMedGoogle Scholar
  • 16 Kurtz SM, Lau EC, Baykal D, Odum SM, Springer BD, Fehring TK. Are ceramic bearings becoming cost-effective for all patients?. J Arthroplasty 2018; 33 (05) 1352-1358
    CrossrefPubMedGoogle Scholar
  • 17 Kurtz SM, Lau E, Baykal D, Springer BD. Outcomes of ceramic bearings after primary total hip arthroplasty in the medicare population. J Arthroplasty 2017; 32 (03) 743-749
    CrossrefPubMedGoogle Scholar
  • 18 Luzzi AJ, Fleischman AN, Matthews CN, Crizer MP, Wilsman J, Parvizi J. The “bundle busters”: incidence and costs of postacute complications following total joint arthroplasty. J Arthroplasty 2018; 33 (09) 2734-2739
    CrossrefPubMedGoogle Scholar
  • 19 Duchman KR, Gao Y, Pugely AJ, Martin CT, Callaghan JJ. Differences in short-term complications between unicompartmental and total knee arthroplasty: a propensity score matched analysis. J Bone Joint Surg Am 2014; 96 (16) 1387-1394
    CrossrefPubMedGoogle Scholar
  • 20 Boening A, Friedrich C, Hedderich J, Schoettler J, Fraund S, Cremer JT. Early and medium-term results after on-pump and off-pump coronary artery surgery: a propensity score analysis. Ann Thorac Surg 2003; 76 (06) 2000-2006
    CrossrefPubMedGoogle Scholar
  • 21 Milton RC, Sperduto RD, Clemons TE, Ferris III FL. ; Age-Related Eye Disease Study Research Group. Centrum use and progression of age-related cataract in the Age-Related Eye Disease Study: a propensity score approach. AREDS report No. 21. Ophthalmology 2006; 113 (08) 1264-1270
    CrossrefPubMedGoogle Scholar
  • 22 Austin PC, Grootendorst P, Anderson GM. A comparison of the ability of different propensity score models to balance measured variables between treated and untreated subjects: a Monte Carlo study. Stat Med 2007; 26 (04) 734-753
    CrossrefPubMedGoogle Scholar
  • 23 Vikram HR, Buenconsejo J, Hasbun R, Quagliarello VJ. Impact of valve surgery on 6-month mortality in adults with complicated, left-sided native valve endocarditis: a propensity analysis. JAMA 2003; 290 (24) 3207-3214
    CrossrefPubMedGoogle Scholar
  • 24 DeCook CA. Outpatient joint arthroplasty: transitioning to the ambulatory surgery center. J Arthroplasty 2019; 34 (7S): S48-S50
    CrossrefPubMedGoogle Scholar
  • 25 Dundon JM, Bosco J, Slover J, Yu S, Sayeed Y, Iorio R. Improvement in total joint replacement quality metrics: year one versus year three of the bundled payments for care improvement initiative. J Bone Joint Surg Am 2016; 98 (23) 1949-1953
    CrossrefPubMedGoogle Scholar
  • 26 Phillips JLH, Rondon AJ, Vannello C, Fillingham YA, Austin MS, Courtney PM. How much does a readmission cost the bundle following primary hip and knee arthroplasty?. J Arthroplasty 2019; 34 (05) 819-823
    CrossrefPubMedGoogle Scholar
  • 27 Free MD, Owen DH, Agius PA, Pascoe EM, Harvie P. Direct anterior approach total hip arthroplasty: an adjunct to an enhanced recovery pathway: outcomes and learning curve effects in surgeons transitioning from other surgical approaches. J Arthroplasty 2018; 33 (11) 3490-3495
    CrossrefPubMedGoogle Scholar
  • 28 Meneghini RM, Elston AS, Chen AF, Kheir MM, Fehring TK, Springer BD. Direct anterior approach: risk factor for early femoral failure of cementless total hip arthroplasty: a multicenter study. J Bone Joint Surg Am 2017; 99 (02) 99-105
    CrossrefPubMedGoogle Scholar
  • 29 Angerame MR, Fehring TK, Masonis JL, Mason JB, Odum SM, Springer BD. Early failure of primary total hip arthroplasty: is surgical approach a risk factor?. J Arthroplasty 2018; 33 (06) 1780-1785
    CrossrefPubMedGoogle Scholar
  • 30 Karidakis GK, Karachalios T. Oxidized zirconium head on crosslinked polyethylene liner in total hip arthroplasty: a 7- to 12-year in vivo comparative wear study. Clin Orthop Relat Res 2015; 473 (12) 3836-3845
    CrossrefPubMedGoogle Scholar
  • 31 Mendenhall S. Hospital resources and implant cost management–—a 2017 update. Orthop Netw News 2018; 29: 9-15
    PubMedGoogle Scholar
  • 32 Chen EY, Lasky R, Dotterweich WA, Niu R, Tybor DJ, Smith EL. Chronic prescription opioid use before and after total hip and knee arthroplasty in patients younger than 65 years. J Arthroplasty 2019; 34 (10) 2319-2323
    CrossrefPubMedGoogle Scholar
  • 33 Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Which clinical and patient factors influence the national economic burden of hospital readmissions after total joint arthroplasty?. Clin Orthop Relat Res 2017; 475 (12) 2926-2937
    CrossrefPubMedGoogle Scholar
  • 34 Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Has health care reform legislation reduced the economic burden of hospital readmissions following primary total joint arthroplasty?. J Arthroplasty 2017; 32 (11) 3274-3285
    CrossrefPubMedGoogle Scholar
  • 35 Katz JN, Losina E, Barrett J. , et al. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population. J Bone Joint Surg Am 2001; 83 (11) 1622-1629
    CrossrefPubMedGoogle Scholar