Adult Reconstruction Call and Prosthetic Joint Infection (PJI) Management Patterns Across the United States

A Cross-Sectional Study

Sravya P. Vajapey, MD, MBA; Mengnai Li, MD, PhD; Andrew H. Glassman, MD, MS

Disclosures

Curr Orthop Pract. 2021;32(5):457-462. 

In This Article

Abstract and Introduction

Abstract

Background: Patients with prosthetic joint infection (PJI) impose a significant burden in total costs, resources consumed, complication rates, and readmission risk. We sought to determine how patients with PJI who were transferred from other hospitals were initially triaged and managed by medical centers across the country.

Methods: An online survey was sent to fellowship program directors or chiefs of adult reconstruction (AR) divisions at academic medical centers. The survey consisted of 11 multiple-choice questions regarding initial management and disposition of patients with PJI who were transferred from other hospitals. Statistical analysis was performed.

Results: Of 96 programs queried, 34 institutions responded. All participating programs performed revision arthroplasties. Thirty-three (97.5%) of the 34 programs accepted transfer of patients with PJI, even if the index arthroplasty procedure was done elsewhere. Twenty-eight (82.4%) responded that a fellowship-trained AR surgeon provides initial treatment to transferred patients with PJI, provided patients are not septic or critically ill. If a patient was septic or critically ill, 12 (35.3%) programs responded that the surgeon on call for general orthopaedics would provide the initial treatment for PJI, usually with irrigation and debridement with retention of components and that, once the patient is medically stabilized, a fellowship-trained AR surgeon would assume care. Roughly 44% of the programs that participated in the survey had a dedicated AR call pool.

Conclusions: There were a variety of models used by academic medical centers for triaging and management of PJI transfer patients. There does not seem to be one single algorithm universally accepted as optimum for initial management of patients.

Level of Evidence: Level III.

Introduction

There is an increasing focus on cost reduction in total joint arthroplasty (TJA). With the passage of the Medicare Access and Children's Health Insurance Program Reauthorization Act in 2015, United States (US) health care has shifted from a volume-based to value-based reimbursement system.[1] Under the Care for Joint Replacement model, the cost of total hip (THA) and total knee arthroplasty (TKA) is calculated based on the 90-day spending data from a participating hospital in addition to the average spending price for other hospitals in the region.[2] Although initially this bundled payment model only applied to Medicare patients, who comprise 55% of all TKAs performed in the US, in recent years this reimbursement system has been adopted by most private insurance companies in an effort to reduce costs.[3] In this value-based system, the parameters that are evaluated include 30-day readmission rates, length of stay, complications, and hospital-acquired conditions.[2] Thus, in order to maximize reimbursement, the orthopaedic provider must be able to maximize quality of care that patients receive while reducing costs.

This incentive to reduce costs has led to a shift from inpatient to outpatient TJA in appropriate patients. Lovald et al.[3] found mean cost savings of $8,527 USD for outpatient versus inpatient TKA. Similarly, Aynardi et al.[4] found mean cost savings of $6,798 USD for outpatient versus inpatient THA. Husted et al.[5] found that, compared to inpatient procedures, outpatient procedures are approximately two-thirds cheaper, if there are no complications such as infection. An important finding to note in all these studies is that outpatient groups had lower comorbidity profiles than inpatient groups.[3–6]

Despite this lower comorbidity profile, the complication rate for outpatient TJA ranges anywhere from 2% to 8%.[7,8] When a complication requiring hospitalization occurs after TJA at a freestanding ambulatory surgery center, these patients are referred to medical centers that provide inpatient care. The surgeon who performed the index arthroplasty may or may not have privileges at the admitting facility. At the authors' large academic medical center, they have become a support system for many practitioners and facilities in the area, particularly for infected total joint replacements. For most patients with prosthetic joint infection (PJI) who are treated at this center, the index arthroplasty procedure was performed elsewhere. Patients with PJI pose a significant burden on the treating institution and the patient in terms of total health care costs, resources consumed, complication rates, and risk of readmission.[9] Currently, there are few data available on how these complex cases are being managed in academic medical centers, which this study considered to be those that offered fellowships in adult reconstruction (AR) surgery.

The goal of this study was to determine patterns of initial and subsequent management of patients who have PJI and were transferred from other hospitals and how the landscape of PJI management is changing with the rising number of primary arthroplasty surgeries performed every year.[10] We sought to answer the following questions: (1) How common is it for academic medical centers to accept patients with PJI when the index arthroplasty procedure was performed elsewhere? (2) Who provides initial care for patients with PJI presenting to the emergency department from another hospital, a fellowship-trained joint replacement surgeon or any board-certified or board-eligible orthopaedic surgeon on call? (3) Do academic medical centers have a dedicated AR call schedule to care for patients with PJI who present as transfers from other hospitals? The management of PJI is complex and involves a multidisciplinary approach that requires many resources. With the answers this study provided, the common practices in PJI management across the country can be better understood in order to develop a standard of care to optimize patient outcomes. The authors hypothesized that most academic medical centers would accept transfer of patients with PJI from other hospitals regardless of whether the index procedures were performed there.

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