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Topics related to the economics, health policy and practice management in orthopaedic surgery.
Contents:
Thu Aug 28 23:53:17 PDT 2008
Bozic KJ, Zurakowski D, Thornhill TS, 1999. "Survivorship analysis of hips treated with core decompression for nontraumatic osteonecrosis of the femoral head." J Bone Joint Surg Am 81 (2): 200-9 [PubMed]
Abstract:
We reviewed the long-term results of core decompression for the treatment of nontraumatic osteonecrosis of the femoral head, performed in thirty-four patients (fifty-four hips) between January 1, 1981, and June 30, 1995. Twenty patients (59 percent) had bilateral involvement. The mean age of the patients at the time of presentation was thirty-eight years (range, twenty-two to eighty-three years). The presumed risk factors were use of corticosteroids (thirty-seven hips), excessive intake of alcohol (eight hips), and use of adrenocorticotropic hormone for the treatment of multiple sclerosis (two hips); the remaining seven hips had idiopathic osteonecrosis. According to a modification of the classification system of Ficat and Arlet in combination with the system of Steinberg et al., thirteen hips were stage I (normal radiographs) preoperatively; seven, stage IIA sclerotic; sixteen, stage IIA cystic or sclerocystic; ten, stage IIB (transitional stage, with a crescent sign); and eight, stage III (collapse). The mean duration of follow-up after the core decompression was 120 months (range, twenty-four to 196 months). The result was considered successful if the patient was asymptomatic, with no progression of the disease, and unsuccessful if there was radiographic failure (progression to stage III [collapse]) or clinical failure (the need for a subsequent operation), or both. The Kaplan-Meier product-limit method was used to estimate clinical and radiographic survival. Overall, twenty-six hips (48 percent) had a satisfactory clinical result and twenty (37 percent) survived according to radiographic criteria. Radiographic or clinical failure, or both, were seen in four of the thirteen stage-I hips, none of the seven stage-IIA sclerotic hips, thirteen of the sixteen stage-IIA cystic or sclerocystic hips, nine of the ten stage-IIB hips, and all eight stage-III hips. On the basis of the Cox proportional-hazards regression model, significant predictors of overall failure included an advanced preoperative radiographic stage (p < 0.0001), a shorter duration of symptoms (p < 0.05), and use of corticosteroids (p < 0.05). No association was found between age, gender, excessive intake of alcohol, or renal transplantation and the overall outcome. Two patients (two hips; 4 percent) had a postoperative complication. One patient had a fracture of the femoral neck, and the other had a hematoma. Our findings suggest that core decompression is a safe and effective procedure for the treatment of stage-I or stage-IIA sclerotic disease. These data also demonstrate the importance of differentiating between stage-IIA sclerotic disease and stage-IIA cystic or sclerocystic disease. We believe that core decompression has a limited role in the operative management of patients who have evidence of cystic changes in the femoral head on plain radiographs.
Bozic KJ, Glazer PA, Zurakowski D, Simon BJ, Lipson SJ, Hayes WC, 1999. "In vivo evaluation of coralline hydroxyapatite and direct current electrical stimulation in lumbar spinal fusion." Spine 24 (20): 2127-33 [PubMed]
Abstract:
STUDY DESIGN: An animal model of posterolateral intertransverse process lumbar spinal fusion using autologous bone, coralline hydroxyapatite, and/or direct current electrical stimulation. OBJECTIVES: To evaluate the effect of an osteoconductive bone graft substitute and direct-current electrical stimulation on the rate of pseudarthrosis in a rabbit spinal fusion model. SUMMARY OF BACKGROUND DATA: Conventional techniques for the surgical treatment of degenerative conditions in the lumbar spine have a substantial failure rate and associated morbidity. Bone graft substitutes and electrical stimulation are alternative techniques to enhance fusion rates and limit the morbidity associated with posterolateral intertransverse process fusion using autologous iliac crest bone graft. METHODS: Fifty-three adult female New Zealand White rabbits underwent single-level lumbar posterolateral intertransverse process fusion. Animals were assigned to one of four groups using either autologous bone (Group I), coralline hydroxyapatite with autologous bone marrow aspirate (Group II), coralline hydroxyapatite with a 40-microA implantable direct current electrical stimulator and bone marrow aspirate (Group III), or coralline hydroxyapatite with a 100-microA implantable direct current electrical stimulator and bone marrow aspirate (Group IV). Animals were killed at 8 weeks, and fused motion segments were subjected to manual palpation, mechanical testing, and radiographic and histologic analysis to assess the fusion mass. RESULTS: Successful fusion was achieved in 57% (8/14) of animals in Group I, 25% (3/12) in Group II, 50% (6/12) in Group III, and 87% (13/15) in Group IV. Mean stiffness and ultimate load to failure were significantly higher in Group IV than in all other groups (P < 0.05). Histologic analysis demonstrated a qualitative increase in fusion mass in Group IV versus all other groups. CONCLUSIONS: Direct-current electrical stimulation increased fusion rates in a dose-dependent manner in a rabbit spinal fusion model. Coralline hydroxyapatite is an osteoconductive bone graft substitute, and thus requires an osteoinductive stimulus to ensure reliable fusion rates. Furthermore, coralline hydroxyapatite and direct current electrical stimulation can be used together to increase fusion rates in a rabbit spinal fusion model while avoiding the morbidity associated with harvesting iliac crest bone.
Bozic KJ, Perez LE, Wilson DR, Fitzgibbons PG, Jupiter JB, 2001. "Mechanical testing of bioresorbable implants for use in metacarpal fracture fixation." J Hand Surg [Am] 26 (4): 755-61 [PubMed]
Abstract:
The purpose of this study was to evaluate the mechanical properties of a bioresorbable plate and screw system that was developed for the treatment of unstable metacarpal fractures and to compare the strength and stiffness of this system with those of conventional titanium plates and screws. Using a 4-point bending test, we measured the strength and stiffness of these implants over a 12-week period of in vitro degradation. Our data suggest that these implants provide stable bending strength and stiffness for 8 weeks and gradually lose their strength over a period of 12 weeks. Further research is necessary to determine whether this level of fixation is adequate to stabilize unstable metacarpal fractures.
Bozic KJ, Rosenberg AG, Huckman RS, Herndon JH, 2003. "Economic evaluation in orthopaedics." J Bone Joint Surg Am 85-A (1): 129-42 [PubMed]
Bozic KJ, Saleh KJ, Rosenberg AG, Rubash HE, 2004. "Economic evaluation in total hip arthroplasty: analysis and review of the literature." J Arthroplasty 19 (2): 180-9 [PubMed]
Abstract:
We performed a bibliographic search of MEDLINE databases from January 1966 to July 2002 to identify English language articles that contained either "cost" or "economic" in combination with "total hip arthroplasty" (THA) in the abstract or title. Each study was then critically reviewed for content, technique, and adherence to established healthcare economic principles. Only 81 of the 153 studies retrieved contained actual economic data. Only 6% of studies adhered to established criteria for a comprehensive health care economic analysis. Although the number of publications regarding economic evaluation of THA is on the rise, the methodologic quality of many of these studies remains inadequate. Future studies should employ sound healthcare economic techniques to properly evaluate and assess the true social and economic value of THA.
Bozic KJ, Rubash HE, 2004. "The painful total hip replacement." Clin Orthop Relat Res (420): 18-25 [PubMed]
Abstract:
Total hip replacement is one of the most common and successful orthopaedic procedures. However, evaluation and treatment of the painful total hip replacement is one of the most difficult challenges for the arthroplasty surgeon. The differential diagnosis includes causes that are intrinsic and extrinsic to the hip. A thorough history and physical examination provide the basis for a focused, efficient workup of the painful total hip replacement. The temporal onset, duration, severity, site, and character of the pain all provide important clues in determining the cause of the painful total hip replacement. The physical examination should focus on tests and maneuvers that reproduce the patient's symptoms. Laboratory tests and radiographic evaluation are used selectively as indicated by the history and physical examination findings. With a careful and thorough evaluation, the cause of the painful total hip replacement can be determined in most patients, and the appropriate treatment can be initiated.
Bozic KJ, Freiberg AA, Harris WH, 2004. "The high hip center." Clin Orthop Relat Res (420): 101-5 [PubMed]
Abstract:
Revision of a failed acetabular component presents many challenges to the arthroplasty surgeon. The goal in most cases should be to reconstruct the acetabulum by positioning the hip center as close as possible to the anatomic hip center. However, severe acetabular bone stock deficiency and distorted acetabular anatomy often preclude placement of the acetabular component at the true anatomic hip center. In these cases, many options exist for reconstruction of the acetabulum, including placement of the cup superiorly at a high hip center. Although biomechanical studies have shown that superolateral placement of the hip center may lead to increased moments and forces across the hip (leading to potentially higher rates of loosening), superior only displacement of the hip center does not seem to adversely affect the forces about the hip. Proximal placement of the hip center facilitates contact between intact, viable host bone and the acetabular implant, thereby reducing the need for structural bone grafts, and increasing the chances for stable bony ingrowth. With proper patient selection and meticulous surgical technique, the high hip center can be a useful technique for reconstruction of the deficient acetabulum in the patient with a loose acetabular component after total hip arthroplasty.
Bozic KJ, Pierce RG, Herndon JH, 2004. "Health care technology assessment. Basic principles and clinical applications." J Bone Joint Surg Am 86-A (6): 1305-14 [PubMed]
Abstract:
Health care technology (defined as all drugs, devices, and medical and surgical procedures used in medical care as well as the organizational and supportive systems within which such care is provided) is widely regarded as an important driver of escalating health care spending in the United States. Many new health care technologies are adopted and used in clinical practice with little or no evidence that their use is associated with improved patient outcomes. Orthopaedic surgeons are facing increasing scrutiny from hospitals and payers regarding the adoption and use of new technology for the treatment of patients with musculoskeletal disease. Health care technology assessment is a growing field that is concerned with the multidisciplinary evaluation of clinical data on the basis of safety and efficacy as well as economic aspects of technology acquisition. Through an understanding of the relevant literature and the concepts of health care technology assessment, orthopaedic surgeons have an opportunity to participate in the assessment process and thus influence clinical and health policy decisions regarding the adoption and use of new and existing technologies in the field of orthopaedic surgery.
Bozic KJ, Kinder J, Meneghini RM, Menegini M, Zurakowski D, Rosenberg AG, Galante JO, 2005. "Implant survivorship and complication rates after total knee arthroplasty with a third-generation cemented system: 5 to 8 years followup." Clin Orthop Relat Res (430): 117-24 [PubMed]
Abstract:
We evaluated implant survivorship, reoperation rates, and complication rates of a group of patients who had total knee arthroplasty with a third-generation cemented prosthetic device using cruciate-retaining and posterior-stabilized designs at 5 to 8 years followup. Three hundred thirty-four consecutive primary total knee arthroplasties (186 cruciate retaining and 148 posterior stabilized) were done in 287 patients at our institution during a 2-year period. Kaplan Meier survivorship using revision for any reason and revision for aseptic loosening as endpoints were 95.9% and 99.5% respectively at 8 years. Nine patients (four with cruciate-retaining total knee arthroplasties, five with posterior-stabilized total knee arthroplasties; 3.1%) had reoperations for any reason. No patients had reoperation for problems related to the patellofemoral joint. Thirty-two patients (11.1%) had intraoperative or postoperative complications. There were no differences in any of the outcomes analyzed between patients who had cruciate-retaining or posterior-stabilized total knee replacements. Our results show that with appropriate patient selection and meticulous attention to surgical technique, excellent clinical and radiographic results can be achieved with a third-generation total knee arthroplasty system at intermediate followup.Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study).
Bozic KJ, Katz P, Cisternas M, Ono L, Ries MD, Showstack J, 2005. "Hospital resource utilization for primary and revision total hip arthroplasty." J Bone Joint Surg Am 87 (3): 570-6 [PubMed]
Abstract:
BACKGROUND: Previous reports have suggested that hospital resource utilization for revision total hip arthroplasty is substantially higher than that for primary total hip arthroplasty. However, current United States Medicare hospital-reimbursement policy does not distinguish between the two procedures. The purpose of this study was to compare primary and revision total hip arthroplasties with regard to actual hospital resource utilization and to identify clinical and demographic factors that are predictive of higher resource utilization associated with these procedures. METHODS: We evaluated the clinical, demographic, and economic data associated with 491 consecutive unilateral primary or revision total hip arthroplasties performed by two surgeons at a single institution between January 2000 and December 2002. The distributions of various demographic, clinical, and utilization characteristics were compared between the two types of arthroplasty procedures, and multivariable linear regression techniques were used to determine independent patient characteristics that were predictive of higher costs for both the primary and the revision procedures. RESULTS: The mean total hospital cost was $31,341 for the revision procedures compared with $24,170 for the primary procedures (p < 0.0001). The mean operative time was 41% longer for the revisions than for the primary procedures (4.5 hours compared with 3.2 hours, p < 0.0001), the mean estimated blood loss was 160% higher (1348 mL compared with 518 mL, p < 0.0001), the mean complication rate was 32% higher (29% compared with 22%, p = 0.072), and the mean length of the hospital stay was 16% longer (6.5 days compared with 5.6 days, p = 0.0005). A higher severity-of-illness score (a measure of preoperative medical health) was predictive of higher resource utilization for both primary and revision arthroplasty even after adjustment for other factors. Preoperative femoral and ace-tabular bone loss and a diagnosis of periprosthetic fracture were predictive of higher resource utilization associated with revision procedures. CONCLUSIONS: At one institution, hospital resource utilization for revision total hip arthroplasty was found to be significantly higher than that for primary arthroplasty. This information is not reflected by current United States Medicare hospital reimbursement, which is the same for all lower-extremity arthroplasty procedures, regardless of the diagnosis, the complexity of the procedure, or the patient's baseline medical health. If these findings are generalizable to other institutions, appropriate reimbursement formulas should be developed to accurately reflect the true costs of caring for patients with a failed total hip arthroplasty.
Bozic KJ, Kinder J, Meneghini RM, Zurakowski D, Rosenberg AG, Galante JO, 2005. "Implant survivorship and complication rates after total knee arthroplasty with a third-generation cemented system: 5 to 8 years followup." Clin Orthop Relat Res (435): 277 [PubMed]
Bozic KJ, Ries MD, 2005. "The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization." J Bone Joint Surg Am 87 (8): 1746-51 [PubMed]
Abstract:
BACKGROUND: Deep infection following total hip arthroplasty is a devastating complication for the patient and a costly one for patients, surgeons, hospitals, and payers. The purpose of this study was to compare revision total hip arthroplasty for infection, revision total hip arthroplasty for aseptic loosening, and primary total hip arthroplasty with respect to their impact on hospital and surgeon resource utilization and referral patterns to a tertiary-care hospital. METHODS: Clinical, demographic, and economic data were obtained for twenty-five consecutive patients with an infection after a total hip replacement who underwent a two-stage revision arthroplasty (Group 1) performed by one of two surgeons, between March 2001 and December 2002, at a single institution. Similar data were collected during the same time-period for a cohort of twenty-five consecutive patients who underwent revision of both components because of aseptic loosening (Group 2) and twenty-five consecutive patients who underwent a primary hip arthroplasty (Group 3). Quantitative and categorical variables were compared among the groups. Referral patterns were examined by reviewing the primary diagnosis for all patients referred to our institution for a revision total hip arthroplasty during a five-year period. RESULTS: Revision procedures for infection were associated with longer operative time, more blood loss, and a higher number of complications compared with revisions for aseptic loosening or primary total hip arthroplasty (p < 0.02 for all). Revisions for infection were also associated with a higher total number of hospitalizations, total number of days in the hospital, total number of operations, total hospital costs, total outpatient visits, and total outpatient charges during the twelve-month period following the index procedure (p < 0.001 for all). The incidence of referrals to our institution for a diagnosis of infection following total hip arthroplasty increased significantly over a five-year period (Spearman rank correlation, 1.0; p = 0.0083), while referral rates for revision for causes other than infection remained relatively constant (Spearman rank correlation, 0.500; p = 0.3910). CONCLUSIONS: The treatment of patients with an infection after a total hip arthroplasty is associated with significantly greater hospital and physician resource utilization compared with the treatment of patients who have a revision because of aseptic loosening or who have a primary total hip arthroplasty. We believe that the lack of incremental reimbursement associated with these procedures results in strong financial disincentives for physicians and hospitals to provide treatment for patients with an infection after a total hip arthroplasty.
Bozic KJ, Durbhakula S, Berry DJ, Naessens JM, Rappaport K, Cisternas M, Saleh KJ, Rubash HE, 2005. "Differences in patient and procedure characteristics and hospital resource use in primary and revision total joint arthroplasty: a multicenter study." J Arthroplasty 20 (7 Suppl 3): 17-25 [PubMed]
Abstract:
A multicenter retrospective cost-identification cohort study was undertaken to analyze clinical, demographic, and economic data for 4533 consecutive total hip arthroplasty (THA) and 3508 consecutive total knee arthroplasty (TKA) procedures performed during a 3-year period in 1 of 3 hospitals. Statistically significant differences were found between primary and revision procedures with respect to patient age, sex, payer type, mean total operative time, use of allograft, average length of hospital stay, discharge disposition, and hospital costs. Significant differences were also found between different types of revision total joint arthroplasty (TJA) procedures. Our findings could be used to help improve the accuracy of administrative claims data related to primary and revision TJA procedures to identify relevant differences in patient characteristics, procedure characteristics, and hospital resource use.
Labovitch RS, Bozic KJ, Hansen E, 2006. "An evaluation of information available on the internet regarding minimally invasive hip arthroplasty." J Arthroplasty 21 (1): 1-5 [PubMed]
Abstract:
The Internet is a popular source of information regarding health care especially when seeking advice on new and less invasive surgical techniques. We evaluated 150 Web sites (3 search engines) for authorship and quality of information regarding minimally invasive hip arthroplasty. The results revealed that 45% were authored by a hospital/university, 26% were news stories, 25% were private medical groups, and 6% were orthopedic industry Web sites. Forty-five percent offered the opportunity to make an appointment, 41% described the surgical technique, and only 15% explained eligibility. Thirteen percent described the risks, whereas 9% made reference to peer-reviewed publications. More than 91% made specific claims regarding the advantages of minimally invasive surgery. Our study suggests the information on the Internet regarding minimally invasive total hip arthroplasty is misleading and of poor quality.
Bozic KJ, Morshed S, Silverstein MD, Rubash HE, Kahn JG, 2006. "Use of cost-effectiveness analysis to evaluate new technologies in orthopaedics. The case of alternative bearing surfaces in total hip arthroplasty." J Bone Joint Surg Am 88 (4): 706-14 [PubMed]
Abstract:
BACKGROUND: Alternative bearing surfaces offer the potential to reduce wear and improve implant longevity following total hip arthroplasty. However, these technologies are associated with higher costs, the potential for unintended consequences, and uncertain benefits in terms of long-term survival of the implants. The purpose of this study was to evaluate the cost-effectiveness of the use of alternative bearings in total hip arthroplasty. METHODS: A decision-analysis model was constructed to estimate the cost-effectiveness of the use of alternative bearings for patients undergoing total hip arthroplasty. Model inputs, including costs, clinical outcome probabilities, and health utility values, were derived from a review of the literature. Sensitivity analyses were performed to evaluate the impact of patient age at the time of surgery, implant costs, and reductions in revision rates on the cost-effectiveness of alternate bearing surfaces. RESULTS: In a population of fifty-year-old patients, use of an alternative bearing with an incremental cost of 2000 dollars would be cost-saving over the individual's lifetime if it were associated with at least a 19% reduction in the twenty-year implant failure rate when compared with the failure rate for a conventional bearing. In a population of patients over the age of sixty-three years, the same implant would be associated with higher lifetime costs than would a conventional bearing, regardless of the presumed reduction in the revision rate. Conversely, an alternative bearing that adds only 500 dollars to the cost of a conventional total hip arthroplasty could be cost-saving in a population of patients over the age of sixty-five years, even if it were associated with only a modest reduction in the revision rate. In a population of patients over the age of seventy-five years, no alternative bearing would be associated with lifetime cost-savings, regardless of the cost or the presumed reduction in the revision rate. CONCLUSIONS: The cost-effectiveness of alternative bearings is highly dependent on the age of the patient at the time of surgery, the cost of the implant, and the associated reduction in the probability of revision relative to that associated with conventional bearings. Our findings provide a quantitative rationale for requiring greater evidence of effectiveness in reducing the probability of implant failure when more costly alternative bearings are being considered, particularly for older patients.
Bozic KJ, Hansen E, 2006. "The economics of minimally invasive total knee arthroplasty." J Knee Surg 19 (2): 149-52 [PubMed]
Ries MD, Bozic KJ, 2006. "Medial gastrocnemius flap coverage for treatment of skin necrosis after total knee arthroplasty." Clin Orthop Relat Res 446: 186-92 [PubMed]
Abstract:
Skin necrosis after total knee arthroplasty is a rare complication that can rapidly lead to deep infection of the prosthetic components. The medial gastrocnemius transposition flap usually provides adequate soft tissue coverage to salvage the total knee arthroplasty. However, variations in defect location and excursion of the muscle flap can affect results. Twelve patients were treated with a medial gastrocnemius transposition flap after total knee arthroplasty. The skin defect that required flap coverage was located over the tibial tubercle or patellar tendon in eight patients (Group 1). The defect extended proximally to the patella or quadriceps tendon in four patients (Group 2). A functioning total knee arthroplasty was salvaged in 11 patients (92%). The medial gastrocnemius flap healed primarily in all patients in Group 1. Three patients in Group 2 required additional fasciocutaneous, lateral gastrocnemius, or free flap coverage, and one patient underwent above knee amputation. The medial gastrocnemius flap is most effective for coverage of distal defects over the tibial tubercle or patellar tendon. Defects that extend more proximally over the patella or quadriceps tendon are more likely to require additional procedures to achieve adequate soft tissue coverage. Level of Evidence: Therapeutic study, level IV (case series). See Author Guidelines for a complete description of levels of evidence.
Ries MD, Cabalo A, Bozic KJ, Anderson M, 2006. "Porous tantalum patellar augmentation: the importance of residual bone stock." Clin Orthop Relat Res 452: 166-70 [PubMed]
Abstract:
Trabecular metal augmentation of bone defects has been associated with favorable bone ingrowth. Animal studies also suggest fibrous tissue attachment to trabecular metal can be achieved. We treated 16 patients with total knee arthroplasty (18 knees) with severe patellar bone loss using trabecular metal patellar reconstruction. The patients were divided into two groups based on the amount of residual patellar bone stock present at the time of surgery: Group 1 (six patients, seven knees) with no patellar bone stock and Group 2 (10 patients, 11 knees) in whom at least 50% of the patellar component surface was covered by host bone. All seven patellar components in Group 1 loosened within 1 year. Two of these developed necrosis of the extensor mechanism leading to extensor mechanism discontinuity. One component in Group 2 became infected and loosened, whereas the remaining 10 components remained stable at minimum 12-month followup. Our results suggest stable fixation of a trabecular metal patellar component can be achieved when residual bone is present for implant fixation, but early loosening is likely to occur when soft tissue is used for fixation to the implant.
Bozic KJ, Wagie A, Naessens JM, Berry DJ, Rubash HE, 2006. "Predictors of discharge to an inpatient extended care facility after total hip or knee arthroplasty." J Arthroplasty 21 (6 Suppl 2): 151-6 [PubMed]
Abstract:
Increased emphasis has been placed on hospital length of stay and discharge planning after total joint arthroplasty (TJA). The purpose of this study was to identify baseline patient characteristics that are predictive of discharge to an inpatient extended care facility (ECF) after TJA. Clinical, demographic, and resource utilization data were analyzed for 7818 consecutive patients who underwent primary or revision TJA at 1 of 3 high-volume TJA centers. A stepwise linear regression model was used to identify predictors of discharge to an ECF. Overall, 29% of patients were discharged to an ECF after TJA. Older age, higher American Society of Anesthesiologists class, Medicare insurance, and female sex were all associated with a higher likelihood of discharge to an ECF. Significant differences in practice patterns were found across hospitals with respect to discharge disposition after TJA. Further study is necessary to determine the appropriate criteria for discharge to an ECF after TJA.
Bickler P, Brandes J, Lee M, Bozic K, Chesbro B, Claassen J, 2006. "Bleeding complications from femoral and sciatic nerve catheters in patients receiving low molecular weight heparin." Anesth Analg 103 (4): 1036-7 [PubMed]
Abstract:
After knee replacement surgery, the use of continuous local anesthetic infusions in femoral and sciatic peripheral nerve catheters is an effective analgesic option. Limited data are available concerning the safety of peripheral nerve infusions in patients receiving low molecular weight heparin thromboprophylaxis. We report three cases of bleeding at femoral and sciatic catheter sites in patients receiving a single daily dose of enoxaparin (40 mg). In all cases, some bleeding was noticed before catheter removal; in one case involving catheter removal 3 h after enoxaparin administration, massive thigh swelling occurred. Physical therapy and discharge from the hospital were delayed in two cases but no other complications were seen. More data are needed to determine if it is necessary to use the same guidelines for managing peripheral nerve infusion catheters in patients receiving enoxaparin as with epidurals and other types of central nerve catheter infusions.
Kim Y, Morshed S, Joseph T, Bozic K, Ries MD, 2006. "Clinical impact of obesity on stability following revision total hip arthroplasty." Clin Orthop Relat Res 453: 142-6 [PubMed]
Abstract:
Similar outcomes have been reported for obese and nonobese patients after primary total hip arthroplasty (THA), indicating obesity is not a contraindication to total hip arthroplasty. However, obese patients may develop implant failure and require revision THA. We compared the outcomes of revision THA in a matched cohort of obese and nonobese patients. Patients were stratified into two groups according to BMI (body mass index, kg/m2): Group 1 included 31 obese patients (BMI > 35), and Group 2 included 62 nonobese patients (BMI < 30) matched on age, gender, and type of revision procedure. Obese patients had increased total operating room time, a higher rate of discharge to a skilled nursing facility, and a higher dislocation rate (p < 0.05). Seven patients in the obese group underwent revision surgery, six of whom underwent additional reoperations to treat recurrent postoperative dislocation. Obese patients should be counseled about the increased risk of dislocation that can occur after revision THA.
Pierce RG, Bozic KJ, Bradford DS, 2007. "Pay for performance in orthopaedic surgery." Clin Orthop Relat Res 457: 87-95 [PubMed]
Abstract:
In recent decades American medicine has undergone tremendous changes. Numerous reimbursement and systems approaches to controlling medical inflation and improving quality have failed to provide cost-effective, high-quality health care in most circumstances. Public and private payers are currently implementing pay for performance, a new reimbursement method linking physician pay to evidence of adherence to performance measures, to constrain costs, encourage efficiency, and maximize value for health care dollars. High-quality research regarding pay for performance and its impact is scarce, particularly in orthopaedic surgery. Although supporters argue pay for performance will remedy the fragmented, costly delivery of health services in the United States, skeptics raise concerns about disagreement over quality guidelines, financial implications for providers and hospitals, inadequate infrastructure, public reporting, system gaming, and physician support. Our survey of orthopaedic surgeons reveals limited understanding of pay for performance, marked skepticism of nonphysician stakeholders' intentions, and a strong desire for greater clinician involvement in shaping the pay for performance movement. As pay for performance will likely be a long-term change that will have an impact on every orthopaedic surgeon, clinician awareness and participation will be fundamental in creating successful pay for performance programs.
Adeoye S, Bozic KJ, 2007. "Direct to consumer advertising in healthcare: history, benefits, and concerns." Clin Orthop Relat Res 457: 96-104 [PubMed]
Abstract:
Physicians, health plans, hospitals, pharmaceutical companies, and medical device manufacturers have all recognized the benefits of marketing their products and services directly to the end user. As a result, there has been tremendous growth of direct-to-consumer advertising (DTCA), illustrated by the increase in spending on DTCA related to prescription drugs from an estimated $55 million in 1991 to $3.2 billion in 2003. This increase in DTCA has sparked vigorous debate among the major stakeholders in healthcare over the benefits and drawbacks of advertising directly to the healthcare consumer. Issues with DTCA include its impact on the doctor-patient relationship, patient education, inappropriate resource utilization, healthcare costs, healthcare quality, and overall patient wellbeing. Orthopaedic surgery is no longer insulated from this expanding trend in DTCA, as orthopaedic surgeons and hospitals are responsible for a substantial portion of DTCA related to orthopaedic devices and procedures. The Food and Drug Administration has a limited regulatory role and limited power related to DTCA due to considerable inefficiencies in its review and disciplinary processes. Therefore, physicians, including orthopaedic surgeons, must take a leadership role on this issue to ensure the integrity of information provided to patients and to protect the sanctity of the doctor-patient relationship.
Bozic KJ, Smith AR, Hariri S, Adeoye S, Gourville J, Maloney WJ, Parsley B, Rubash HE, 2007. "The 2007 ABJS Marshall Urist Award: The impact of direct-to-consumer advertising in orthopaedics." Clin Orthop Relat Res 458: 202-19 [PubMed]
Abstract:
Direct-to-consumer advertising (DTCA) has become an influential factor in healthcare delivery in the United States. We evaluated the influence of DTCA on surgeon and patient opinions and behavior in orthopaedics by surveying orthopaedic surgeons who perform hip and knee arthroplasties and patients who were scheduled to have hip or knee arthro-plasty. Respondents were asked for their opinions of and experiences with DTCA, including the influence of DTCA on surgeon and patient decision making. Greater than 98% of surgeon respondents had experience with patients who were exposed to DTCA. The majority of surgeon respondents reported DTCA had an overall negative impact on their practice and their interaction with patients (74%), and their patients often were confused or misinformed about the appropriate treatment for their condition based on an advertisement (77%). Fifty-two percent of patient respondents recalled seeing or hearing advertisements related to hip or knee arthroplasty. These patients were more likely to request a specific type of surgery or brand of implant from their surgeon and to see more than one surgeon before deciding to have surgery. Direct-to-consumer advertising seems to play a substantial role in surgeon and patient decision making in orthopaedics. Future efforts should be aimed at improving the quality and accuracy of information contained in consumer-directed advertisements related to orthopaedic implants and procedures.
Pierce RG, Bozic KJ, Hall BL, Breivis J, 2007. "Health care technology assessment: implications for modern medical practice. Part II. Decision making on technology adoption." Am J Orthop 36 (2): 71-6 [PubMed]
Abstract:
Health care technology assessment, the multidisciplinary evaluation of clinical and economic aspects of technology, has come to have an increasingly important role in health policy and clinical decision-making. In Part I--Understanding Technology Adoption and Analyses--this review addressed the difficult challenges posed by assessment and provided a guide to the methodologies used. Part II presents the factors that drive the technology choices made by patients, by individual physicians, by provider groups, and by hospital administrators.
Bozic KJ, 2007. "Health policy and practice management issues in orthopaedic surgery: editorial comment." Clin Orthop Relat Res 457: 2 [PubMed]
Herndon JH, Hwang R, Bozic KJ, Bozic KH, 2007. "Healthcare technology and technology assessment." Eur Spine J 16 (8): 1293-302 [PubMed]
Abstract:
New technology is one of the primary drivers for increased healthcare costs in the United States. Both physician and industry play important roles in the development, adoption, utilization and choice of new technologies. The Federal Drug Administration regulates new drugs and new medical devices, but healthcare technology assessment remains limited. Healthcare technology assessment originated in federal agencies; today it is decentralized with increasing private sector efforts. Innovation is left to free market forces, including direct to consumer marketing and consumer choice. But to be fair to the consumer, he/she must have free knowledge of all the risks and benefits of a new technology in order to make an informed choice. Physicians, institutions and industry need to work together by providing proven, safe, clinically effective and cost effective new technologies, which require valid pre-market clinical trials and post-market continued surveillance with national and international registries allowing full transparency of new products to the consumer--the patient.
Pierce RG, Bozic KJ, Hall BL, Breivis J, 2007. "Health care technology assessment: implications for modern medical practice. Part I. Understanding technology adoption and analyses." Am J Orthop 36 (1): 11-4 [PubMed]
Abstract:
In the modern era of rapidly rising medical costs, health care technology assessment--multidisciplinary evaluation of clinical and economic aspects of technology--has assumed an increasingly important role in health policy and clinical decision-making. This review examines health care technology adoption, its impact on medical and surgical practice, and recent trends in health care technology assessment. Part I discusses the difficult challenges posed by assessment and provides a guide to the methodologies used.
Berven S, Smith A, Bozic K, Bradford DS, 2007. "Pay-for-performance: considerations in application to the management of spinal disorders." Spine 32 (11 Suppl): S33-8 [PubMed]
Abstract:
STUDY DESIGN: Descriptive review. OBJECTIVES: To describe the role of pay-for-performance as a health care policy that has a significant influence on the management of spinal disorders, and to consider parameters of quality measure that are likely to optimize the efficacy of a pay-for-performance system as applied to spine care. SUMMARY OF BACKGROUND DATA: Pay-for-performance arrangements have been adopted in many areas of medicine with limited evidence for improvement in quality of care. There is an important role for a system that will improve quality of care in the management of spinal disorders. The absence of accepted evidence-based approaches to the management of spinal disorders makes the choice of parameters to measure for quality difficult. RESULTS: Performance parameters to consider include a continuum of measures from process variables that focus on a discrete component of the health care experience, to outcome variables that encompass the end result of care. There are advantages and limitations to each parameter discussed. CONCLUSION: A pay-for-performance system in the management of spinal disorders should include both process variables that measure safety and outcome variables that reflect the end result of care.
Morshed S, Bozic KJ, Ries MD, Malchau H, Colford JM, 2007. "Comparison of cemented and uncemented fixation in total hip replacement: a meta-analysis." Acta Orthop 78 (3): 315-26 [PubMed]
Abstract:
BACKGROUND: The choice of optimal implant fixation in total hip replacement (THR)--fixation with or without cement--has been the subject of much debate. METHODS: We performed a systematic review and meta-analysis of the published literature comparing cemented and uncemented fixation in THR. RESULTS: No advantage was found for either procedure when failure was defined as either: (A) revision of either or both components, or (B) revision of a specific component. No difference was seen between estimates from registry and single-center studies, or between randomized and non-randomized studies. Subgroup analysis of type A studies showed superior survival with cemented fixation in studies including patients of all ages as compared to those that only studied patients 55 years of age or younger. Among type B studies, cemented titanium stems and threaded cups were associated with poor survival. An association was found between difference in survival and year of publication, with uncemented fixation showing relative superiority over time. INTERPRETATION: While the recent literature suggests that the performance of uncemented implants is improving, cemented fixation continues to outperform uncemented fixation in large subsets of study populations. Our findings summarize the best available evidence qualitatively and quantitatively and provide important information for future research.
Bozic KJ, Smith AR, Mauerhan DR, 2007. "Pay-for-performance in orthopedics: implications for clinical practice." J Arthroplasty 22 (6 Suppl 2): 8-12 [PubMed]
Abstract:
The United States health care system currently faces many challenges, including rising costs and variable quality. Health care purchasers and payers are demanding increased transparency and accountability for their health care dollars. Pay-for-performance (P4P) initiatives, which seek to link provider reimbursement to measures of quality and efficiency, have been introduced by both private and government payers. Despite their appeal over current provider reimbursement systems, which reward volume and intensity of services rather than quality and efficiency, P4P programs face numerous challenges in their implementation, including difficulty defining and measuring quality, high costs associated with collecting and analyzing performance data, problems with risk adjustment, lack of additional funding to reward quality, unintended consequences of provider gaming and patient deselection, and impact on low-tier, low-quality providers. Future efforts should involve collaboration among providers, payers, and policy makers to ensure that P4P programs are implemented safely and effectively.
Bozic KJ, Beringer D, 2007. "Economic considerations in minimally invasive total joint arthroplasty." Clin Orthop Relat Res 463: 20-5 [PubMed]
Abstract:
Minimally invasive techniques for hip and knee arthroplasty have been gaining popularity in recent years. Despite the apparent widespread enthusiasm for these procedures, there is little published evidence demonstrating superior quality of life outcomes directly attributable to the surgical technique. The current debate regarding the value of minimally invasive surgery extends beyond the demonstrated or potential clinical benefits of these procedures. Economic considerations of patients, surgeons, hospitals, and payers are prominent factors in this debate and will continue to influence the adoption of minimally invasive surgical procedures. Developing an understanding of the barriers posed by our healthcare delivery system to minimally invasive surgical procedures and how these barriers impact each of the stakeholders in the healthcare system will foster a rational deployment of these promising new approaches to hip and knee arthroplasty in the future.
(C) 2007 Lippincott Williams & Wilkins, Inc.
Beringer DC, Patel JJ, Bozic KJ, 2007. "An overview of economic issues in computer-assisted total joint arthroplasty." Clin Orthop Relat Res 463: 26-30 [PubMed]
Abstract:
Computer-assisted techniques have been successfully used in many surgical procedures. More recently, computer-assisted surgery has been used to improve the accuracy and reproducibility of implant alignment in total hip and knee arthroplasty procedures. However, the impact of computer-assisted surgery on long-term clinical outcomes and implant survivorship in total joint arthroplasty has yet to be documented. The adoption of computer-assisted surgical systems for use in total joint arthroplasty will be heavily influenced by the economic impact on the various stakeholders in the health-care system. Currently, there are mixed financial incentives for surgeons, hospitals, and payers to adopt and use computer-assisted surgical techniques for total joint arthroplasty. Careful consideration of the impact of computer-assisted surgery on surgeon and hospital productivity as well as the financial contribution of this technology to hospital profit margins would provide valuable insight into the adoption and widespread use of computer-assisted surgery.
(C) 2007 Lippincott Williams & Wilkins, Inc.
Novak EJ, Silverstein MD, Bozic KJ, 2007. "The cost-effectiveness of computer-assisted navigation in total knee arthroplasty." J Bone Joint Surg Am 89 (11): 2389-97 [PubMed]
Abstract:
BACKGROUND: Total knee arthroplasty is one of the most clinically successful and cost-effective interventions in medicine. However, implant malalignment, especially in the coronal plane, is a common cause of early failure following total knee arthroplasty. Computer-assisted surgery has been employed during total knee arthroplasty to improve the precision of component alignment. The purpose of the present study was to evaluate the cost-effectiveness of computer-assisted surgery to determine whether the improved alignment achieved with computer navigation provides a sufficient decrease in failure rates and revisions to justify the added cost. METHODS: A decision-analysis model was used to estimate the cost-effectiveness of computer-assisted surgery in total knee arthroplasty. Model inputs, including costs, effectiveness, and clinical outcome probabilities, were obtained from a review of the literature. Sensitivity analyses were performed to evaluate the impact of component-alignment precision with use of computer-assisted and mechanical alignment guides, total knee arthroplasty failure rates secondary to malalignment, and costs of computer-assisted surgery systems on the cost-effectiveness of computer navigation in total knee arthroplasty. RESULTS: Computer-assisted surgery is both more effective and more expensive than mechanical alignment systems. Given an additional cost of $1500 per operation, a 14% improvement in coronal alignment precision (within 3 degrees of neutral mechanical axis), and an elevenfold increase in revision rates at fifteen years with coronal malalignment (54% compared with 4.7%), the incremental cost of using computer-assisted surgery is $45,554 per quality-adjusted life-year gained. Cost-savings is achieved if the added cost of computer-assisted surgery is $629 or less per operation. Variability in published clinical outcomes, however, introduces uncertainty in determining the cost-effectiveness. CONCLUSIONS: Computer-assisted surgery is potentially a cost-effective or cost-saving addition to total knee arthroplasty. However, the cost-effectiveness is sensitive to variability in the costs of computer navigation systems, the accuracy of alignment achieved with computer navigation, and the probability of revision total knee arthroplasty with malalignment.
Hariri S, Bozic KJ, Lavernia C, Prestipino A, Rubash HE, 2007. "Medicare physician reimbursement: past, present, and future." J Bone Joint Surg Am 89 (11): 2536-46 [PubMed]
Provencher MT, Bozic KJ, Haydon R, Lau JT, Vallier HA, 2008. "AOA 2005 John J. Fahey, MD, Memorial North American Traveling Fellowship: Fellows' Travel Diary." J Bone Joint Surg Am 90 (1): 205-7 [PubMed]
Bozic KJ, Jacobs JJ, 2008. "Technology assessment and adoption in orthopaedics: lessons learned." J Bone Joint Surg Am 90 (4): 689-90 [PubMed]
Patel J, Ries MD, Bozic KJ, 2008. "Extensor mechanism complications after total knee arthroplasty." Instr Course Lect 57: 283-94 [PubMed]
Abstract:
Extensor mechanism complications after total knee arthroplasty are relatively uncommon but potentially devastating. The etiology of these complications, which includes patellofemoral instability, periprosthetic patellar fracture, and disruptions of the quadriceps tendon and patellar ligament, has become better defined in recent years, with a subsequent decrease in the incidence, primarily resulting from changes in surgical technique and component design. In addition to addressing the patient's specific failure mechanism, the treatment of extensor mechanism complications after total knee arthroplasty may include nonsurgical management, primary repair, or reconstruction with autogenous, allogeneic, or synthetic tissue. Prevention of these complications, the foremost goal, is achieved through identification of patient and procedure risk factors, meticulous surgical technique, including vigilance during exposure and retractor placement, and a high index of suspicion both during and after the procedure.
Sharifi E, Sharifi H, Morshed S, Bozic K, Diab M, 2008. "Cost-effectiveness analysis of periacetabular osteotomy." J Bone Joint Surg Am 90 (7): 1447-56 [PubMed]
Abstract:
BACKGROUND: A lack of long-term outcomes data following periacetabular osteotomy makes it difficult for surgeons to recommend the most appropriate procedure to young patients who might be candidates for a joint-preserving procedure. In this study, we compared the cost-effectiveness of periacetabular osteotomy with total hip arthroplasty in terms of cost per quality-adjusted life year for the young adult. METHODS: A decision model was constructed for a cost-utility analysis of periacetabular osteotomy compared with total hip arthroplasty. Outcome probabilities and effectiveness were derived from the literature. Effectiveness was expressed in quality-adjusted life years gained. Cost data were compiled and verified from our institution. Costs and utilities were discounted in accord with the United States Panel on Cost-Effectiveness in Health and Medicine. Principal outcome measures were average incremental costs, incremental effectiveness, incremental quality-adjusted life years, and net health benefits. Multivariate sensitivity analysis was used to assess the contribution of included variables in the model's outcomes. RESULTS: For Tönnis grade-1 coxarthrosis, periacetabular osteotomy dominates with an average incremental cost-effectiveness of $7856 per quality-adjusted life year and an average incremental effectiveness of 0.15. For Tönnis grade-2 coxarthrosis, periacetabular osteotomy is, on the average, more cost-effective than total hip arthroplasty with an incremental cost-effectiveness of $824 per quality-adjusted life year, but it is less effective than total hip arthroplasty, on the average, with an incremental effectiveness of -1.4 quality-adjusted life years. Periacetabular osteotomy becomes more cost-effective at a longevity of 5.5 years for Tönnis grade-1 coxarthrosis and 18.25 years for Tönnis grade-2 coxarthrosis. In Tönnis grade-3 coxarthrosis, total hip replacement becomes the dominant treatment strategy. CONCLUSIONS: Periacetabular osteotomy is, on the average, more cost-effective in Tönnis grade-1 and grade-2 coxarthrosis, while it is both more costly and less effective in Tönnis grade-3 coxarthrosis. These findings can inform clinical decision-making in the absence of long-term data. On the basis of this model, periacetabular osteotomy is preferable to total hip arthroplasty in Tönnis grade-1 and grade-2 coxarthrosis when the patient is sufficiently young and when functionality in sports is important.
Slover JD, Tosteson AN, Bozic KJ, Rubash HE, Malchau H, 2008. "Impact of hospital volume on the economic value of computer navigation for total knee replacement." J Bone Joint Surg Am 90 (7): 1492-500 [PubMed]
Abstract:
BACKGROUND: An aim of the use of computer navigation is to reduce rates of revisions of total knee replacements by improving the alignment achieved at the surgery. However, the decision to adopt this technology may be difficult for some centers, especially low-volume centers, where the cost of purchasing this equipment may be high. The purpose of this study was to examine the impact of hospital volume on the cost-effectiveness of this new technology in order to determine its feasibility and the level of evidence that should be sought prior to its adoption. METHODS: A Markov decision model was used to evaluate the impact of hospital volume on the cost-effectiveness of computer-assisted knee arthroplasty in a theoretical cohort of sixty-five-year-old patients with end-stage arthritis of the knee to coincide with the peak incidence of knee arthroplasty in the United States. RESULTS: Computer-assisted surgery becomes less cost-effective as the annual hospital volume decreases, as the cost of the navigation increases, and as the impact on revision rates decreases. Centers at which 250, 150, and twenty-five computer-navigated total knee arthroplasties are performed per year will require a reduction of the annual revision rate of 2%, 2.5%, and 13%, respectively, per year over a twenty-year period for computer navigation to be cost-effective. CONCLUSIONS: Computer navigation is less likely to be a cost-effective investment in health-care improvement in centers with a low volume of joint replacements, where its benefit is most likely to be realized. However, it may be a cost-effective technology for centers with a higher volume of joint replacements, where the decrease in the rate of knee revision needed to make the investment cost-effective is modest, if improvements in revision rates with the use of this technology can be realized.
Bozic KJ, Jaramillo D, DiCanzio J, Zurakowski D, Kasser JR, 1999 Jan-Feb. "Radiographic appearance of the normal distal tibiofibular syndesmosis in children." J Pediatr Orthop 19 (1): 14-21 [PubMed]
Abstract:
In adults, a tibiofibular clear space (i.e., distance from the incisura fibularis to the medial fibula) of > or = 6 mm or a loss of tibiofibular overlap has been reported to correlate with injury to the distal tibiofibular syndesmosis. We reviewed anteroposterior (AP), lateral, and mortise ankle radiographs from 106 children (50 boys, 56 girls) aged 1-15 years in an attempt to assess whether these criteria are applicable to children. The incisura was detectable at a mean age of 8.2 years for girls and 11.2 years for boys. The range of tibiofibular clear space among the 48 children with a detectable incisura was 2-8 mm; seven (23%) of these 48 children had a clear space of > or = 6 mm in one or more views. The mean age at which the tibiofibular overlap began to appear on the AP view was 5 years for both genders, whereas on the mortise view, it was 10 years for girls and 16 years for boys. The criteria used to evaluate the integrity of the distal tibiofibular syndesmosis in adults do not apply to children in this normal study population.
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