Publications by authors named "Eric L Smith"

124 Publications

An Enhanced Understanding of Culture-Negative Periprosthetic Joint Infection with Next-Generation Sequencing: A Multicenter Study.

J Bone Joint Surg Am 2022 Jun 20. Epub 2022 Jun 20.

Rothman Institute at Thomas Jefferson, Philadelphia, Pennsylvania.

Background: The challenges of culture-negative periprosthetic joint infection (PJI) have led to the emergence of molecular methods of pathogen identification, including next-generation sequencing (NGS). While its increased sensitivity compared with traditional culture techniques is well documented, it is not fully known which organisms could be expected to be detected with use of NGS. The aim of this study was to describe the NGS profile of culture-negative PJI.

Methods: Patients undergoing revision hip or knee arthroplasty from June 2016 to August 2020 at 14 institutions were prospectively recruited. Patients meeting International Consensus Meeting (ICM) criteria for PJI were included in this study. Intraoperative samples were obtained and concurrently sent for both routine culture and NGS. Patients for whom NGS was positive and standard culture was negative were included in our analysis.

Results: The overall cohort included 301 patients who met the ICM criteria for PJI. Of these patients, 85 (28.2%) were culture-negative. A pathogen could be identified by NGS in 56 (65.9%) of these culture-negative patients. Seventeen species were identified as common based on a study-wide incidence threshold of 5%. NGS revealed a polymicrobial infection in 91.1% of culture-negative PJI cases, with the set of common species contributing to 82.4% of polymicrobial profiles. Escherichia coli, Cutibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus ranked highest in terms of incidence and study-wide mean relative abundance and were most frequently the dominant organism when occurring in polymicrobial infections.

Conclusions: NGS provides a more comprehensive picture of the microbial profile of infection that is often missed by traditional culture. Examining the profile of PJI in a multicenter cohort using NGS, this study demonstrated that approximately two-thirds of culture-negative PJIs had identifiable opportunistically pathogenic organisms, and furthermore, the majority of infections were polymicrobial.

Level Of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.21.01061DOI Listing
June 2022

Activation of Tumor-Cell STING Primes NK-Cell Therapy.

Cancer Immunol Res 2022 Aug;10(8):947-961

Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.

Activation of the stimulator of interferon genes (STING) pathway promotes antitumor immunity but STING agonists have yet to achieve clinical success. Increased understanding of the mechanism of action of STING agonists in human tumors is key to developing therapeutic combinations that activate effective innate antitumor immunity. Here, we report that malignant pleural mesothelioma cells robustly express STING and are responsive to STING agonist treatment ex vivo. Using dynamic single-cell RNA sequencing of explants treated with a STING agonist, we observed CXCR3 chemokine activation primarily in tumor cells and cancer-associated fibroblasts, as well as T-cell cytotoxicity. In contrast, primary natural killer (NK) cells resisted STING agonist-induced cytotoxicity. STING agonists enhanced migration and killing of NK cells and mesothelin-targeted chimeric antigen receptor (CAR)-NK cells, improving therapeutic activity in patient-derived organotypic tumor spheroids. These studies reveal the fundamental importance of using human tumor samples to assess innate and cellular immune therapies. By functionally profiling mesothelioma tumor explants with elevated STING expression in tumor cells, we uncovered distinct consequences of STING agonist treatment in humans that support testing combining STING agonists with NK and CAR-NK cell therapies.
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http://dx.doi.org/10.1158/2326-6066.CIR-22-0017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9357206PMC
August 2022

Proceedings from the Blood and Marrow Transplant Clinical Trials Network Myeloma Intergroup Workshop on Immune and Cellular Therapy in Multiple Myeloma.

Transplant Cell Ther 2022 Aug 21;28(8):446-454. Epub 2022 May 21.

Roswell Park Comprehensive Cancer Center, Buffalo, New York.

The Blood and Marrow Transplant Clinical Trials Network (BMT CTN) Myeloma Intergroup conducted a workshop on Immune and Cellular Therapy in Multiple Myeloma on January 7, 2022. This workshop included presentations by basic, translational, and clinical researchers with expertise in plasma cell dyscrasias. Four main topics were discussed: platforms for myeloma disease evaluation, insights into pathophysiology, therapeutic target and resistance mechanisms, and cellular therapy for multiple myeloma. Here we provide a comprehensive summary of these workshop presentations.
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http://dx.doi.org/10.1016/j.jtct.2022.05.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9357156PMC
August 2022

Effect of the COVID-19 Pandemic on Rates of Ninety-Day Peri-Prosthetic Joint and Surgical Site Infections after Primary Total Joint Arthroplasty: A Multicenter, Retrospective Study.

Surg Infect (Larchmt) 2022 Jun 20;23(5):458-464. Epub 2022 May 20.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.

The impact of the coronavirus 2019 (COVID-19) pandemic on the rate of primary total joint arthroplasty (TJA) peri-prosthetic joint infection (PJI) and superficial surgical site infections (SSI) is currently unknown. The purpose of this multicenter study was to evaluate any changes in the rates of 90-day PJI or 30-day SSI, including trends in microbiology of the infections, during the COVID-19 pandemic compared to the three years prior. An Institutional Review Board-approved, multicenter, retrospective study was conducted with five participating academic institutions across two healthcare systems in the northeastern United States. Primary TJA patients from the years 2017-2019 were grouped as a pre-COVID-19 pandemic cohort and patients from the year 2020 were grouped as a COVID-19 pandemic cohort. Differences in patient demographics, PJI, SSI, and microbiology between the two cohorts were assessed. A total of 14,844 TJAs in the pre-COVID-19 pandemic cohort and 5,453 TJAs in the COVID-19 pandemic cohort were evaluated. There were no substantial differences of the combined 90-day PJI and 30-day superficial SSI rates between the pre-COVID-19 pandemic cohort (0.35%) compared with the COVID-19 pandemic cohort (0.26%; p = 0.303). This study did not find any change in the rates of 90-day PJI or 30-day superficial SSI in patients undergoing primary TJA between a pre-COVID-19 pandemic and COVID-19 pandemic cohort. Larger national database studies may identify small but substantial differences in 90-day PJI and 30-day superficial SSI rates between these two time periods. Our data may support continued efforts to maintain high compliance with hand hygiene, use of personal protective equipment, and limited hospital visitation whenever possible.
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http://dx.doi.org/10.1089/sur.2022.012DOI Listing
June 2022

Capture Rate of V(D)J Sequencing for Minimal Residual Disease Detection in Multiple Myeloma.

Clin Cancer Res 2022 05;28(10):2160-2166

Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida.

Purpose: Minimal residual disease (MRD) negativity is a strong predictor for outcome in multiple myeloma. To assess V(D)J clonotype capture using the updated Adaptive next-generation sequencing (NGS) MRD assay in a clinical setting, we analyzed baseline and follow-up samples from patients with multiple myeloma who achieved deep clinical responses.

Experimental Design: A total of 159 baseline and 31 follow-up samples from patients with multiple myeloma were sequenced using the NGS MRD assay. Baseline samples were also sequenced using a targeted multiple myeloma panel (myTYPE). We estimated ORs with 95% confidence intervals (CI) for clonotypes detection using logistic regression.

Results: The V(D)J clonotype capture rate was 93% in baseline samples with detectable genomic aberrations, indicating presence of tumor DNA, assessed through myTYPE. myTYPE-positive samples had significantly higher V(D)J clonotype detection rates in univariate (OR, 7.3; 95% CI, 2.8-22.6) and multivariate analysis (OR, 4.4; 95% CI, 1.4-16.9; P = 0.016). Higher disease burden was associated with higher probability of V(D)J clonotype capture, meanwhile no such association was found for age, gender, or type of heavy or light immunoglobulin chain. All V(D)J clonotypes detected at baseline were detected in MRD-positive samples indicating that the V(D)J clonotypes remained stable and did not undergo further rearrangements during follow-up. Of the 31 posttreatment samples, 12 were MRD-negative using the NGS MRD assay.

Conclusions: NGS for V(D)J rearrangements in multiple myeloma offers a reliable and sensitive method for MRD tracking with high detection rates in the clinical setting.
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http://dx.doi.org/10.1158/1078-0432.CCR-20-2995DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9179004PMC
May 2022

Drivers of Unequal Healthcare Costs in the Nonoperative Treatment of Late-Stage Knee Osteoarthritis Prior to Primary Total Knee Arthroplasty.

J Arthroplasty 2022 May 4. Epub 2022 May 4.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts.

Background: In the United States, patients with late-stage knee osteoarthritis (OA) often undergo several nonoperative treatments and related procedures prior to total knee arthroplasty. The costs of these treatments and procedures are substantial, and the variation in healthcare costs among different groups of patients may exist. The purpose of this study is to examine these costs and determine the drivers of costs in patients with the highest healthcare expenditure.

Methods: An observational cohort study was conducted using the IBM Watson Health MarketScan databases from January 1, 2017 to December 31, 2019. The primary outcome was the cost of payments for nonoperative procedures which included (i) physical therapy (PT), (ii) bracing, (iii) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS), (iv) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen, and (v) knee-specific imaging.

Results: Among the 24,492 patients included in the study, the total payments per patient for nonoperative care were $3,735 ± 3,049 in the highest payment quartile (Q4) and $137 ± 70 in the lowest payment quartile (Q1). Per-patient-per-month costs generally increased across quartiles for procedures. Comparing Q4 to Q1, the largest changes in prevalence were found in IA-HA (348×), bracing (10×), and PT (7×). Patients who were prescribed IA-HA and PT had a 28.3-times and 4.8-times greater likelihood, respectively, to be a higher-paying patient.

Conclusion: Unequal healthcare costs in the nonoperative treatment of late-stage knee OA are driven by differences in prevalent management strategies. Overall healthcare expenditure may be reduced if only guideline-concordant treatments are used.
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http://dx.doi.org/10.1016/j.arth.2022.04.040DOI Listing
May 2022

The Cost-Effectiveness of Extended Oral Antibiotic Prophylaxis for Infection Prevention After Total Joint Arthroplasty in High-Risk Patients.

J Arthroplasty 2022 Apr 25. Epub 2022 Apr 25.

Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts.

Background: Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients.

Methods: Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT).

Results: Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates.

Conclusion: The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition.
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http://dx.doi.org/10.1016/j.arth.2022.04.025DOI Listing
April 2022

Total Joint Arthroplasty in Homeless Patients at an Urban Safety Net Hospital.

J Am Acad Orthop Surg 2022 Jun 15;30(11):523-527. Epub 2022 Mar 15.

From the Department of Orthopaedics, New England Baptist Hospital, Boston, MA (Niu, Fang, and Smith), the Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA (Egan), Boston University School of Medicine, Boston, MA (Duru), and the Department of Orthopedic Surgery, Boston Medical Center, Boston, MA (Alley and Freccero).

Introduction: Homelessness is a key social determinant of health, and the patient population has grown to over 580,000. Total joint arthroplasty (TJA) is an effective treatment of symptomatic end-stage osteoarthritis of the hip and knee and has been shown to improve health-related quality of life in the general population. However, the literature on the outcomes of TJA among homeless patients is limited.

Methods: We retrospectively reviewed 442 patients who underwent primary, unilateral TJA between June 1, 2016, and August 31, 2017, at an urban, tertiary, academic safety net hospital. Based on self-reported living status, we classified 28 homeless patients and 414 control nonhomeless patients. Fisher exact tests, Student t-tests, and multivariate logistic regression were used to compare the demographics, preoperative conditions, and surgical outcomes between the two groups.

Results: The homeless group were younger, more often male, and smokers; had alcohol use disorder; and used illicit drugs. After controlling for age, sex, and preoperative medical and social conditions, homeless patients were 15.83 times more likely to have an emergency department visit (adjusted odds ratio, 15.83; 95% confidence interval, 5.05 to 49.59; P < 0.0001) within 90 days but had similar rates of readmission (P = 0.25), revision surgery (P = 0.38), and prosthetic joint infection (P = 0.25) when compared with nonhomeless patients.

Discussion: Although homeless patients did not have higher rates of readmission or revision surgery, homelessness still presents unique challenges for the TJA patients and providers. With careful preoperative optimization and collaborative support, however, the benefits of TJA may outweigh the risk of poor outcomes for these patients.
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http://dx.doi.org/10.5435/JAAOS-D-21-00651DOI Listing
June 2022

Comparing the Risk of Osteonecrosis of the Femoral Head Following Intra-Articular Corticosteroid and Hyaluronic Acid Injections.

J Bone Joint Surg Am 2022 Mar 11. Epub 2022 Mar 11.

Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts.

Background: Although intra-articular corticosteroid injections (CSIs) are a cornerstone in the nonoperative management of hip pathology, recent reports have raised concerns that they may cause osteonecrosis of the femoral head (ONFH). However, these studies might have been limited by nonrepresentative patient samples. Therefore, the purpose of this study was to assess the incidence of ONFH after CSI and compare it with the incidence in a similar patient population that received a non-CSI injection.

Methods: This was a retrospective propensity-matched cohort study of patients in the MarketScan database who underwent an intra-articular hip injection from 2007 to 2017. Patients receiving hip CSIs were matched 4:1 with patients receiving hip hyaluronic acid injections (HAIs) based on age, sex, geographic region, comorbidities, type of hip pathology, injection year, and baseline and follow-up time using propensity scores. The patients' first injections were identified, and the time to development of ONFH was analyzed using Kaplan-Meier curves and Cox proportional-hazards models. Patients with a history of osteonecrosis or those who received both types of injections were excluded.

Results: A total of 3,710 patients undergoing intra-articular hip injection were included (2,968 CSIs and 742 HAIs; mean [standard deviation] age, 53.1 [9.2] years; 55.4% men). All baseline factors were successfully matched between the groups (all p > 0.57). The estimated cumulative incidence (95% confidence interval [CI]) of ONFH for CSI and HAI patients was 2.4% (1.8% to 3.1%) versus 2.1% (1.1% to 3.5%) at 1 year and 2.9% (2.2% to 3.7%) versus 3.0% (1.7% to 4.8%) at 2 years (hazard ratio, 1.05; 95% CI, 0.59 to 1.84; p = 0.88). The results held across a range of sensitivity analyses.

Conclusions: The incidence of ONFH after intra-articular hip injection was similar between patients who received CSIs and those who received HAIs. Although this study could not determine whether intra-articular injections themselves (regardless of the drug that was used) lead to ONFH, the results suggest that ONFH after CSI often may be due, in part, to the natural course of the underlying disease. Future randomized controlled trials are needed to definitively answer this question; in the interim, clinicians may be reassured that they may continue judicious use of CSIs as clinically indicated.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.21.01043DOI Listing
March 2022

CD19-directed chimeric antigen receptor T cell therapy in Waldenström macroglobulinemia: a preclinical model and initial clinical experience.

J Immunother Cancer 2022 02;10(2)

Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.

Background: Waldenström macroglobulinemia (WM) is an incurable disease and, while treatable, can develop resistance to available therapies and be fatal. Chimeric antigen receptor (CAR) T cell therapy directed against the CD19 antigen has demonstrated efficacy in relapsed or refractory B lymphoid malignancies, and is now approved for B cell acute lymphoblastic leukemia and certain B cell lymphomas. However, CAR T therapy has not been evaluated for use in WM.

Methods And Results: We performed preclinical studies demonstrating CAR T cell activity against WM cells in vitro, and developed an in vivo murine model of WM which demonstrated prolonged survival with use of CAR T therapy. We then report the first three patients with multiply relapsed and refractory WM treated for their disease with CD19-directed CAR T cells on clinical trials. Treatment was well tolerated, and observed toxicities were consistent with those seen in CAR T treatment for other diseases, and no grade 3 or higher cytokine release syndrome or neurotoxicity events occurred. All three patients attained at least a clinical response to treatment, including one minimal residual disease-negative complete response, though all three eventually developed recurrent disease between 3 and 26 months after initial treatment.

Conclusions: This report summarizes preclinical and clinical activity of CD19-directed CAR T therapy in WM, demonstrating early tolerability and efficacy in patients with WM, and representing a possible treatment option in patients with heavily pretreated and relapsed or refractory WM. Larger studies evaluating CAR T therapy in WM are warranted, along with further evaluation into mechanisms of resistance to CAR T therapy.
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http://dx.doi.org/10.1136/jitc-2021-004128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8852764PMC
February 2022

Reducing Narcotic Usage With 0.5% Bupivacaine Periarticular Injections in Total Knee Arthroplasty.

J Arthroplasty 2022 05 19;37(5):851-856. Epub 2022 Jan 19.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA.

Background: Periarticular injections (PAIs) and adductor canal blocks (ACBs) are widely accepted pain management strategies for total knee arthroplasty (TKA); however, the optimal anesthetic concentration to provide adequate pain relief while avoiding toxicity remains controversial. The purpose of this study is to evaluate the efficacy of different anesthetic concentrations for PAI alone and in combination with ACB.

Methods: This retrospective cohort study of patients undergoing primary TKAs between January 2019 and November 2020 included 3 groups: 0.25% PAI (50 cc of 0.25% bupivacaine PAI diluted with 50 cc of saline and ketorolac), 0.5% PAI (50 cc of 0.5% bupivacaine with 50 cc of saline and ketorolac), and PAI + ACB (ultrasound-guided preoperative anesthesiologist-administered ACB and 0.25% PAI).

Results: In total, 368 TKAs were analyzed (123 0.25%, 132 0.5%, and 113 PAI + ACB). Total overall hospital narcotic usage in oral morphine equivalents (OME) was significantly lower for the 0.5% group (120.09 vs 165.26 and 175.75) compared to the 0.25% and PAI + ACB groups, respectively (P < .0001). Cumulative OME for the first 3 shifts was also lower for 0.5% (68.7 vs 83.7 and 76.4) compared to the 0.25% and PAI + ACB groups, respectively (P = .030). Total postoperative narcotics in OME were significantly lower for 0.5% (617.9 vs 825.2 and 1047.6) than 0.25% and PAI + ACB, respectively (P = .0003). Number of prescriptions within 6 weeks postoperatively were also significantly lower for 0.5% (1.7) than 0.25% (2.1) and PAI + ACB (2.4) (P = .0003).

Conclusion: Patients receiving 0.5% PAI had lower narcotic usage compared to 0.25% PAI or PAI + ACB. ACB may be eliminated without compromising pain control if the dose of local anesthetic in the PAI is sufficiently high.
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http://dx.doi.org/10.1016/j.arth.2022.01.026DOI Listing
May 2022

Association Between Surgical Opioid Prescriptions and Opioid Initiation by Opioid-Naïve Spouses.

Ann Surg 2021 Dec 23. Epub 2021 Dec 23.

Department of Orthopaedic Surgery, Brigham and Women's Hospital / Harvard Medical School, Boston, MA Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA.

Objective: To determine whether surgical opioid prescriptions are associated with increased risk of opioid initiation by operative patients' spouses.

Summary Background Data: Adverse effects of surgical opioids on operative patients have been well described. Whether risks of surgical opioids extend to operative patients' family members is unknown.

Methods: This was a retrospective cohort study of opioid-naïve, married patients undergoing 1 of 11 common surgeries from 1/1/2011-6/30/2017. The adjusted association between surgical opioid prescriptions and opioid initiation by the operative patient's spouse in the 6-months following surgery was assessed. Secondary analyses assessed how this association varied with postoperative time.

Results: There were 318,022 patients (mean ± SD age 48.8 ± 9.3 years; 49.5% women). Among the 50,833(16.0%) patients that did not fill a surgical opioid prescription, 2,152(4.2%) had spouses who filled an opioid prescription within 6-months of their surgery. In comparison, among the 267,189(84.0%) patients who filled a surgical opioid prescription, 15,026(5.6%) had spouses who filled opioid prescriptions within 6-months of their surgery (unadjusted P < .001; adjusted odds ratio[aOR] 1.37, 95%CI 1.31-1.43, P < .001). Associated risks were only mildly elevated in postoperative month 1 (aOR 1.11, 95%CI 1.00-1.23, P = 0.04) before increasing to a peak in postoperative month 3 (aOR 1.57, 95%CI 1.39-1.76, P < .001).

Conclusions: Surgical opioid prescriptions were associated with increased risk of opioid initiation by spouses of operative patients, suggesting that risks associated with surgical opioids may extend beyond the surgical patient. These findings may highlight the importance of preoperative counseling on safe opioid use, storage, and disposal for both patients and their partners.
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http://dx.doi.org/10.1097/SLA.0000000000005350DOI Listing
December 2021

Total Knee Arthroplasty Hospital Costs by Time-Driven Activity-Based Costing: Robotic vs Conventional.

Arthroplast Today 2022 Feb 10;13:43-47. Epub 2021 Dec 10.

Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA, USA.

Background: Total knee arthroplasty (TKA) represents a major national health expenditure. The last decade has seen a surge in robotic-assisted TKA (roTKA); however, literature on the costs of roTKA as compared to conventional TKA (cTKA) is limited. The purpose of this study was to assess the costs associated with roTKA as compared to cTKA.

Methods: This was a retrospective cohort cost-analysis study of patients undergoing primary, elective roTKA or cTKA from July 2020 to March 2021. Time-driven activity-based costing (TDABC) was used to determine granular costs. Patient demographics, medical/surgical details, and costs were compared.

Results: A total of 2058 TKAs were analyzed (1795 cTKAs and 263 roTKAs). roTKA patients were more often male (50.2% vs 42.3%;  = .016), and discharged home (98.5% vs 93.7%;  = .017), and had longer operating room (OR) time (144.6 vs 130.9 minutes; < .0001), and lower length of stay (LOS) (1.8 vs 2.1 days; < .0001). roTKA costs were 2.17× greater for supplies excluding implant ( < .0001), 1.18× for total supplies ( < .0001), 1.12× for OR personnel ( < .0001), and 1.05× for total personnel ( = .0001). Implant costs were similar ( = .076), but 0.98× cheaper for post-anesthesia care unit personnel ( = .018) and 0.84× for inpatient personnel ( < .0001). Overall hospital costs for roTKA were 1.10× more than cTKA ( < .0001).

Conclusion: roTKA had higher total hospital costs than cTKA. Despite a lower LOS, the longer OR time with higher supply and personnel costs resulted in a costlier procedure. Understanding the costs of roTKA is essential when considering the value (ie, outcomes per dollars spent) of this modern technology.
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http://dx.doi.org/10.1016/j.artd.2021.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8666607PMC
February 2022

Variation in the Profit Margin for Different Types of Total Joint Arthroplasty.

J Bone Joint Surg Am 2022 03;104(5):459-464

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts.

Background: As health care shifts to a value-based model with bundled-payment methods, it is important to understand the costs and reimbursements of arthroplasty procedures that represent the largest expenditure of Medicare. The aim of the present study was to characterize the variation in (1) total hospital costs, (2) reimbursement, and (3) profit margin for different arthroplasty procedures.

Methods: The total hospital costs of total knee arthroplasty (TKA), total hip arthroplasty (THA), anatomic total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), and total ankle arthroplasty (TAA) were calculated with use of time-driven activity-based costing at an orthopaedic institution from 2018 to 2020. The average reimbursement for each type of procedure was determined. Profit margin, defined as the reimbursement profit after direct costs, was calculated by deducting the average time-drive activity-based total hospital costs from the reimbursement value. Multivariate analyses were performed to evaluate the associations between costs, reimbursement, and profit margins.

Results: There were 13,545 arthroplasty procedures analyzed for this study, including 6,636 TKAs, 5,902 THAs, 346 TSAs, 577 RSAs, and 84 TAAs. Costs and reimbursement were highest for TAA. THA and TKA resulted in the highest profit margins, whereas RSA resulted in the lowest. The strongest associations with profit margin were private insurance (0.46547), age (-0.22732), and implant cost (-0.19240).

Conclusions: THA and TKA had greater profit margins overall than TAA and upper-extremity arthroplasty in general. Profit margins for RSA, TSA, and TAA were all at least 28% lower than those for TKA or THA. Lower-volume arthroplasty procedures were associated with decreased profit margins. Study findings suggest that optimizing implant costs and length of stay are important for sustaining institutional fiscal health when performing shoulder and ankle arthroplasty surgery.
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http://dx.doi.org/10.2106/JBJS.21.00223DOI Listing
March 2022

No Association Between Intrauterine Contraceptive Devices and Musculoskeletal Hip Joint Pain.

Arthrosc Sports Med Rehabil 2021 Oct 20;3(5):e1407-e1412. Epub 2021 Aug 20.

Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School.

Purpose: To investigate the association between intrauterine device (IUD) use and hip pain, orthopaedic visits for hip pain, and arthroscopic hip surgery.

Methods: This was a retrospective cohort study of patients aged 18-44 years old using either IUDs or subdermal implants for contraception in a large commercial claims database (MarketScan) from 2012 to 2015. All patients had at least 12 months of continuous enrollment both before and after contraceptive placement. Patients with a history of hip pain or surgery were excluded. The primary outcome was new hip pain. Secondary outcomes included visiting an orthopaedic or sports medicine provider for a hip complaint, intra-articular hip injection, and arthroscopic hip surgery. Outcomes were analyzed with Cox proportional-hazard models.

Results: We identified a total of 242,383 patients, including 216,541 (89.3%) with IUDs and 25,842 (10.7%) with subdermal contraceptive implants. In time-to-event analysis, IUDs (vs implants) were not associated with increased risk of new hip pain diagnoses (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.87-1.03,  = .21). In contrast, both age ( < .001) and region ( < .001) were associated with increased risk of new hip pain. Similar results were seen for the secondary outcomes, including risk of orthopaedic visits for hip complaints (HR 1.06, 95% CI 0.83-1.35,  = .63), intra-articular injections of the hip (HR 0.94, 95% CI 0.63-1.41,  = .77), and hip arthroscopy procedures (HR 1.13, 95% CI 0.53-2.40,  = .75).

Conclusions: In this study, we found no evidence that IUDs were associated with hip pain or surgery.

Level Of Evidence: Level III, retrospective cohort.
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http://dx.doi.org/10.1016/j.asmr.2021.07.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8527253PMC
October 2021

Reply.

Authors:
Eric L Smith

Orthopedics 2021 Sep-Oct;44(5):262-263. Epub 2021 Sep 1.

New England Baptist Hospital and Tufts University School of Medicine, Boston, Massachusetts.

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http://dx.doi.org/10.3928/01477447-20210819-11DOI Listing
October 2021

Depletion of high-content CD14 cells from apheresis products is critical for successful transduction and expansion of CAR T cells during large-scale cGMP manufacturing.

Mol Ther Methods Clin Dev 2021 Sep 16;22:377-387. Epub 2021 Jul 16.

Michael G. Harris Cell Therapy and Cell Engineering Facility, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

With the US Food and Drug Administration (FDA) approval of four CD19- and one BCMA-targeted chimeric antigen receptor (CAR) therapy for B cell malignancies, CAR T cell therapy has finally reached the status of a medicinal product. The successful manufacturing of autologous CAR T cell products is a key requirement for this promising treatment modality. By analyzing the composition of 214 apheresis products from 210 subjects across eight disease indications, we found that high CD14 cell content poses a challenge for manufacturing CAR T cells, especially in patients with non-Hodgkin's lymphoma and multiple myeloma caused by the non-specific phagocytosis of the magnetic beads used to activate CD3 T cells. We demonstrated that monocyte depletion via rapid plastic surface adhesion significantly reduces the CD14 monocyte content in the apheresis products and simultaneously boosts the CD3 content. We established a 40% CD14 threshold for the stratification of apheresis products across nine clinical trials and demonstrated the effectiveness of this procedure by comparing manufacturing runs in two phase 1 clinical trials. Our study suggests that CD14 content should be monitored in apheresis products, and that the manufacturing of CAR T cells should incorporate a step that lessens the CD14 cell content in apheresis products containing more than 40% to maximize the production success.
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http://dx.doi.org/10.1016/j.omtm.2021.06.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411225PMC
September 2021

Characterizing Intraoperative Vasopressor Use in Total Knee Arthroplasty: A Retrospective Cohort Study.

J Knee Surg 2021 Aug 4. Epub 2021 Aug 4.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts.

Preoperative optimization and protocols for joint replacement care pathways have led to decreased length of stay (LOS)and narcotic use, and are increasingly important in delivering quality, cost savings, and shifting appropriate cases to an outpatient setting. The intraoperative use of vasopressors is independently associated with increased LOS and risk of adverse postoperative events including death, and in total hip arthroplasty, there is an increased risk for intensive care unit (ICU) admission. Our aim is to characterize the patient characteristics associated with vasopressor use specifically in total knee arthroplasty (TKA). We retrospectively reviewed the electronic medical records of a cohort of patients who underwent inpatient primary TKA at a single academic hospital from January 1, 2017 to December 31, 2018. Demographics, comorbidities, perioperative factors, and intraoperative medication administration were compared with multivariate regression to identify patients who may require intraoperative vasopressors. Out of these, 748 patients underwent TKA, 439 patients required intraoperative vasopressors, while 307 did not. Significant independent predictors of vasopressor use were older age (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 1.03-1.08) and history of a prior cerebrovascular accident (CVA; OR = 11.80, CI: 1.48-93.81). While not significant, male sex (OR = 0.72, CI: 0.50-1.04) and regional anesthesia (OR = 0.64, CI: 0.40-1.05) were nearing significance as negative independent predictors of vasopressor use. In a secondary analysis, we did not observe an increase in complications attributable to vasopressor administration intraoperatively. In conclusion, nearly 59% of patients undergoing TKA received intraoperative vasopressor support. History of stroke and older age were significantly associated with increased intraoperative vasopressor use. As the first study to examine vasopressor usage in a TKA patient population, we believe that understanding the association between patient characteristics and intraoperative vasopressor support will help orthopaedic surgeons select the appropriate surgical setting during preoperative optimization.
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http://dx.doi.org/10.1055/s-0041-1731721DOI Listing
August 2021

Finding the optimal partner to pair with bispecific antibody therapy for multiple myeloma.

Blood Cancer Discov 2021 Jul;2(4):297-299

Department of Medical Oncology, Dana-Farber Cancer Center, Boston, Massachusetts.

BCMA/CD3ε-targeted bispecific antibody (BsAb) therapy represents a promising T-cell redirecting immunotherapy to treat relapsed and refractory multiple myeloma (MM). However, rational combination strategies will most likely be key to achieve a long-lasting immune response. In this issue, Meermeier and colleagues investigate BsAb therapy in a syngeneic MM model and elucidate that partnering with cyclophosphamide is associated with tempered activation, mitigated exhaustion of T-cells, and is superior to pomalidomide or bortezomib in enhancing durable anti-MM efficacy.
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http://dx.doi.org/10.1158/2643-3230.BCD-21-0073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8265983PMC
July 2021

Early Discharge After Total Hip Arthroplasty at an Urban Tertiary Care Safety Net Hospital: A 2-Year Retrospective Cohort Study.

J Am Acad Orthop Surg 2021 Oct;29(20):894-899

From the Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA (Alley, Freccero), the Boston University School of Medicine, Boston, MA (Shewmaker, Vaickus), and the New England Baptist Hospital, Boston, MA (Niu, Smith).

Introduction: Previous studies have shown that shorter inpatient stays after total hip arthroplasty (THA) are safe and effective for select patient populations with limited medical comorbidity and perioperative risk. The purpose of our study was to compare the postoperative complications because they relate to the length of hospital stay at a safety net hospital in the urban area of the United States.

Methods: We retrospectively reviewed the medical records of 236 patients who underwent primary THA in 2017 at an urban safety net hospital. We collected data on demographics, medical comorbidities, and surgical admission information. Patients were categorized as "early discharge" if they were discharged on postoperative day 0 to 1 and "standard discharge" if they were discharged on postoperative day 2 to 5. The outcomes of interest were 90-day and 2-year postoperative complications, emergency department visit, readmissions, and revision surgeries. Data were analyzed using t-test or chi-square test for univariate analysis and linear logistic regression for controlled analysis.

Results: Compared with the standard discharge group, there were markedly more male patients in the early discharge group (44.5% versus 80%). Early discharge patients were markedly younger (53.3 versus 59.5 years old), more likely to be White/non-Hispanic (64.4% versus 42.4%) and less likely to have heart disease and diabetes (2.2% versus 15.2% and 2.2% versus 19.9%, respectively). With adjustment for these potential confounders, no notable difference was observed in all-type complications, emergency department visits, readmission, or revision surgery between the two groups.

Discussion: This study confirmed that early discharge after THA is as safe as standard discharge in a safety net hospital with appropriate preoperative risk screening. Increased perioperative counseling and optimization of social and medical risk factors mitigated possible risk factors for increased length of stay and surgical complication.
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http://dx.doi.org/10.5435/JAAOS-D-20-01006DOI Listing
October 2021

Incorporation of bacterial immunoevasins to protect cell therapies from host antibody-mediated immune rejection.

Mol Ther 2021 12 2;29(12):3398-3409. Epub 2021 Jul 2.

Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Weill Cornell Medicine, New York, NY 10065, USA. Electronic address:

Cellular therapies are engineered using foreign and synthetic protein sequences, such as chimeric antigen receptors (CARs). The frequently observed humoral responses to CAR T cells result in rapid clearance, especially after re-infusions. There is an unmet need to protect engineered cells from host-versus-graft rejection, particularly for the advancement of allogeneic cell therapies. Here, utilizing the immunoglobulin G (IgG) protease "IdeS," we programmed CAR T cells to defeat humoral immune attacks. IdeS cleavage of host IgG averted Fc-dependent phagocytosis and lysis, and the residual F(ab') fragments remained on the surface, providing cells with an inert shield from additional IgG deposition. "Shield" CAR T cells efficiently cleaved cytotoxic IgG, including anti-CAR antibodies, detected in patient samples and provided effective anti-tumor activity in the presence of anti-cell IgG in vivo. This technology may be useful for repeated human infusions of engineered cells, more complex engineered cells, and expanding widespread use of "off-the-shelf" allogeneic cellular therapies.
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http://dx.doi.org/10.1016/j.ymthe.2021.06.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8636170PMC
December 2021

Image-Guided Intra-articular Hip Injections and Risk of Infection After Hip Arthroscopy.

Am J Sports Med 2021 07 23;49(9):2482-2488. Epub 2021 Jun 23.

Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA.

Background: Although intra-articular injections are important in the management of patients who may later undergo hip arthroscopy, conflicting data are available regarding the safety of such injections when administered within 3 months of surgery. Furthermore, despite the increasing use of image-guided intra-articular hip injections, it is unknown whether the type of imaging modality used is associated with infection after hip arthroscopy.

Purpose: To assess the risk of infection associated with image-guided intra-articular injections before hip arthroscopy and, secondarily, compare that risk between ultrasound (US) and fluoroscopic (FL) guidance.

Study Design: Cohort study; Level of evidence, 3.

Methods: This was a retrospective cohort study of patients in a large national insurance database who underwent hip arthroscopy between 2007 and 2017. Patients were required to have continuous enrollment from at least 1 year before to 6 months after hip arthroscopy. Patient age, sex, geographic region, medical history, surgical details, and hip injections were collected. Patients who underwent injection ≤3 months preoperatively and >3 to ≤12 months preoperatively were compared with patients who did not undergo preoperative injection. Bivariate analyses and multivariable logistic regressions were used to assess the association between ipsilateral preoperative hip injection and surgical site infection within 6 months of surgery.

Results: We identified 17,987 patients (36.3% female; mean ± SD age, 37.6 ± 14.0 years) undergoing hip arthroscopy, 2276 (12.7%) of whom had an image-guided hip injection in the year preceding surgery (53.0% FL). Patients who underwent intra-articular injection ≤3 months preoperatively had similar infection rates to patients who did not undergo preoperative injection in the year before surgery for both the FL (0.46% vs 0.46%; ≥ .995) and the US cohorts (0.50% vs 0.46%; = .76). Results persisted in adjusted analysis (FL ≤3 months: OR, 1.04; 95% CI, 0.32-3.37; = .94; US ≤3 months: OR, 1.19; 95% CI, 0.36-3.90; = .78). Similar results were seen for patients undergoing injections >3 to ≤12 months preoperatively.

Conclusion: Postoperative infection was rare in patients undergoing intra-articular hip injection ≤3 months before hip arthroscopy and was no more common than in patients not undergoing preoperative injection. Moreover, no differences were seen in infection risk between US and FL guidance. Although intra-articular hip injections should always be administered with careful consideration, these results do not suggest that these injections are uniformly contraindicated in the 3 months preceding hip arthroscopy.
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http://dx.doi.org/10.1177/03635465211022798DOI Listing
July 2021

Episode-of-Care Costs for Revision Total Joint Arthroplasties by Decadal Age Groups.

Geriatrics (Basel) 2021 May 11;6(2). Epub 2021 May 11.

New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120, USA.

The demand for revision total joint arthroplasties (rTJAs) is expected to increase as the age of the population continues to rise. Accurate cost data regarding hospital expenses for differing age groups are needed to deliver optimal care within value-based healthcare (VBHC) models. The aim of this study was to compare the total in-hospital costs by decadal groups following rTJA and to determine the primary drivers of the costs for these procedures. Time-driven activity-based costing (TDABC) was used to capture granular hospital costs. A total of 551 rTJAs were included in the study, with 294 sexagenarians, 198 septuagenarians, and 59 octogenarians and older. Sexagenarians had a lower ASA classification (2.3 vs. 2.4 and 2.7; < 0.0001) and were more often privately insured (66.7% vs. 24.2% and 33.9%; < 0.0001) as compared to septuagenarians and octogenarians and older, respectively. Sexagenarians were discharged to home at a higher rate (85.3% vs. 68.3% and 34.3%; < 0.0001), experienced a longer operating room (OR) time (199.8 min vs. 189.7 min and 172.3 min; = 0.0195), and had a differing overall hospital length of stay (2.8 days vs. 2.7 days and 3.6 days; = 0.0086) compared to septuagenarians and octogenarians and older, respectively. Sexagenarians had 7% and 23% less expensive personnel costs from post-anesthesia care unit (PACU) to discharge ( < 0.0001), and 1% and 24% more expensive implant costs ( = 0.077) compared to septuagenarians and octogenarians and older, respectively. Sexagenarians had a lower total in-hospital cost for rTJAs by 0.9% compared to septuagenarians but 12% more expensive total in-hospital costs compared to octogenarians and older ( = 0.185). Multivariate linear regression showed that the implant cost (0.88389; < 0.0001), OR time (0.12140; < 0.0001), personnel cost from PACU through to discharge (0.11472; = 0.0007), and rTHAs (-0.03058; < 0.0001) to be the strongest associations with overall costs. Focusing on the implant costs and OR times to reduce costs for all age groups for rTJAs is important to provide cost-effective VBHC.
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http://dx.doi.org/10.3390/geriatrics6020049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162336PMC
May 2021

Dynamics of minimal residual disease in patients with multiple myeloma on continuous lenalidomide maintenance: a single-arm, single-centre, phase 2 trial.

Lancet Haematol 2021 Jun;8(6):e422-e432

Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA. Electronic address:

Background Lenalidomide maintenance improves progression-free survival for patients with multiple myeloma, although its optimal duration is unknown. Clearance of minimal residual disease (MRD) in the bone marrow results in superior outcomes, although its attainment or sustainment does not alter clinical decision-making. Studies that have evaluated MRD serially are limited in length. We therefore aimed to evaluate longitudinal changes in MRD-status (dynamics) and their association with progression-free survival in patients with multiple myeloma.

Methods: In this single-centre, single-arm, phase 2 study, we enrolled patients aged 18 years and older from the Memorial Sloan Kettering Cancer Center (New York, NY, USA) who had newly diagnosed multiple myeloma following unrestricted frontline therapy and an Eastern Cooperative Oncology Group Performance Status of 2 or lower, including patients who started maintenance before study enrolment. All participants received lenalidomide maintenance at 10 mg for 21 days of 28-day cycles until progression or unacceptable toxic effects for up to 5 years on protocol. The primary endpoint was progression-free survival at 60 months per protocol and key secondary endpoints were MRD rates after completion of the 12th, 24th, and 36th cycle of maintenance and the association between progression-free survival and annual measurement of MRD status. MRD was assessed from first-pull bone marrow aspirates at baseline and annually by flow cytometry per International Myeloma Working Group criteria, (limit of detection of at least 1 × 10) up to a maximum of 5 years. Patients who completed at least four cycles of treatment were included in the analysis of the primary endpoint, and patients who had completed at least one dose of treatment on protocol were assessable for secondary endpoints. The study was registered at ClinicalTrials.gov, NCT02538198, and is now closed to accrual.

Findings: Between Sept 8, 2015, and Jan 25, 2019, 108 patients (100 evaluable for the primary endpoint) were enrolled. Median follow-up was 40·7 months (95% CI 38·7-45·0). At 60 months, progression-free survival was 64% (95% CI 52-79). Median progression-free survival was unreached (95% CI unreached-unreached). MRD dynamics were assessed using 340 MRD assessments done over 5 years for 103 evaluable patients. Patients who sustained MRD negativity for 2 years (n=34) had no recorded disease progression at median 19·8 months (95% CI 15·8-22·3) past the 2-year maintenance landmark. By contrast, patients who lost their MRD-negative responses (n=10) were more likely to progress than those with sustained MRD negativity (HR infinite; p<0·0001) and those with persistent MRD positivity (HR 5·88, 95% CI 1·18-33·33; p=0·015) at the 2-year landmark. Haematological and non-haematological serious adverse events occurred in 19 patients (18%). The most common adverse events of grade 3 or worse were decreased lymphocyte count in 48 (44%) patients and decreased neutrophil count in 47 (44%) patients. One death occurred on study due to sepsis and heart failure and was considered unrelated to the study drug.

Interpretation: Serial measurements of MRD allow for dynamic assessment of risk for disease progression. Early intervention should be investigated for patients with loss of MRD negativity. Sustained MRD positivity is not categorically an unfavourable outcome and might portend prolonged stability of low-level disease.

Funding: Memorial Sloan Kettering and Celgene.
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http://dx.doi.org/10.1016/S2352-3026(21)00130-7DOI Listing
June 2021

Bias Does Not Exist in Treating Knee Periprosthetic Joint Infection Among Patients With Substance Use Disorder.

Orthopedics 2021 May-Jun;44(3):e385-e389. Epub 2021 May 1.

Debridement, antibiotics with implant retention (DAIR), and 2-stage revision are standard surgical interventions for treating knee periprosthetic joint infection (PJI). Patients with substance use disorder (SUD), especially addictive drug use disorder (DUD), have been shown to receive inferior medical care in many specialties compared with nonusers. The authors identified patients with a diagnosis of PJI after knee arthroplasty who received either DAIR or 2-stage revision with the Nationwide Inpatient Sample (NIS) database from 2010 to 2014. Patients were stratified into 2 groups, patients with DUD and nonusers, based on 5th Edition, criteria. Descriptive analysis was conducted to show the national trend for knee PJI treatment among the 2 patient groups. Multivariate logistic regression was used to compare the prevalence of DAIR and 2-stage revision between these 2 groups, adjusted for likely confounders, including age, sex, income, race, and comorbidities. Among the 11,331 patients with knee infection, 139 (1.23%) had DUD. Compared with nonusers, patients with DUD were significantly younger (<.001), had more chronic conditions (<.001), and were predominantly in lower income quartiles (=.046). The 2 groups did not differ in sex and race (=.072 and =.091, respectively). The authors found that 30.22% of patients with DUD and 36.36% of nonusers received DAIR. The difference in these proportions was not statistically significant (=.135). The results did not change after adjustment for confounding factors (=.509). The findings suggested that bias does not exist among orthopedic surgeons who choose DAIR or 2-stage revision for knee PJI among patients with DUD. [. 2021;44(3):e385-e389.].
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http://dx.doi.org/10.3928/01477447-20210414-10DOI Listing
July 2021

The Cost of Hip and Knee Revision Arthroplasty by Diagnosis-Related Groups: Comparing Time-Driven Activity-Based Costing and Traditional Accounting.

J Arthroplasty 2021 08 20;36(8):2674-2679.e3. Epub 2021 Mar 20.

Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA.

Background: Traditional hospital cost accounting (TA) has innate disadvantages that limit the ability to meaningfully measure care pathways and quality improvement. Time-driven activity-based costing (TDABC) allows a meticulous account of costs in primary total joint arthroplasty (TJA). However, differences between TA and TDABC have not been examined in revision hip and knee TJA (rTJA). We aimed to compare total costs of rTJA by the diagnosis-related group (DRG), measured by TDABC vs TA.

Methods: Overall costs were calculated for rTJA care cycles by DRG for 2 years of financial data (2018-2019) at our single-specialty orthopedic institution using TA and TDABC. Costs derived from TDABC, based on time and resources used, were compared with costs derived from TA based on historical costs. Proportions of implant and nonimplant costs were measured to total TA costs.

Results: Seven hundred ninety-three rTJAs were included in this study, with TA methodology resulting in higher cost estimates. The total cost per DRG 468, rTJA with no comorbidities or complications (CC), DRG 467, rTJA with CC, and DRG 466, rTJA with major CC, estimated by TDABC was 69%, 67%, and 49% of the estimation by TA, respectively. Implant and nonimplant costs represented different proportions between methodologies.

Conclusion: Considerable differences exist, as TA estimations were 31%-51% higher than TDABC. The true cost is likely a value between the estimations, but TDABC presents granular and patient-specific cost data. TDABC for rTJA provides valuable bottom-up information on cost centers in the care pathway and, with targeted interventions, may lead to a more optimal delivery of value-based health care.
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http://dx.doi.org/10.1016/j.arth.2021.03.041DOI Listing
August 2021

Financial Burden of Revision Hip and Knee Arthroplasty at an Orthopedic Specialty Hospital: Higher Costs and Unequal Reimbursements.

J Arthroplasty 2021 08 23;36(8):2680-2684. Epub 2021 Mar 23.

Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA.

Background: As demand for primary total joint arthroplasty (TJA) continues to grow, a proportionate increase in revision TJA (rTJA) is expected. It is essential to understand costs and reimbursement of rTJA as our country moves to bundled payment models. We aimed (1) to characterize implant and total hospital costs, (2) assess reimbursement, and (3) determine revenue for rTJA in comparison with primary TJA.

Methods: The average implant and total hospital cost of all primary and rTJA procedures by diagnosis-related group (DRG) was calculated using time-driven activity-based costing at an orthopedic hospital from 2018 to 2020. Average reimbursement and payer type were assessed by DRG. Revenue was calculated by deducting average time-driven activity-based costing total costs from reimbursement.

Results: 13,946 arthroplasties were included in the study. Implant cost comprised 55.8% of total hospital costs for rTJA DRG 468, compared with 43.6% of total hospital costs for primary TJA DRG 470. Total hospital costs for DRG 468 were 61.1% more than DRG 470. Reimbursement for rTJA was 1.23x more than primary TJA. Private payers paid 23.2% more than Medicare for rTJA. Margin for DRG 468 was 1.5% less than primary DRG 470.

Conclusion: rTJA requires more hospital resources and costs than primaries, yet hospital reimbursement may be inadequate with the additional expenditures necessary to provide optimal care. If hospitals cannot perform revision services under the current reimbursement model, patient access may be limited. Implant costs are a major contributor to overall rTJA cost. Strategies are needed to reduce revision implant costs to improve value of care.

Level Of Evidence: Level III, economic and decision analysis.
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http://dx.doi.org/10.1016/j.arth.2021.03.044DOI Listing
August 2021

Differences in Hospital Costs among Octogenarians and Nonagenarians Following Primary Total Joint Arthroplasty.

Geriatrics (Basel) 2021 Mar 9;6(1). Epub 2021 Mar 9.

New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120, USA.

The proportion of patients over the age of 90 years continues to grow, and the anticipated demand for total joint arthroplasty (TJA) in this population is expected to rise concomitantly. As the country shifts to alternative reimbursement models, data regarding hospital expenses is needed for accurate risk-adjusted stratification. The aim of this study was to compare total in-hospital costs following primary TJA in octogenarians and nonagenarians, and to determine the primary drivers of cost. This was a retrospective analysis from a single institution in the U.S. We used time-drive activity-based costing (TDABC) to capture granular total hospital costs for each patient. 889 TJA's were included in the study, with 841 octogenarians and 48 nonagenarians. Nonagenarians were more likely to undergo total hip arthroplasty (THA) (70.8% vs. 42.4%; < 0.0001), had higher ASA classification (2.6 vs. 2.4; = 0.049), and were more often privately insured (35.4% vs. 27.8%; = 0.0001) as compared to octogenarians. Nonagenarians were more often discharged to skilled nursing facilities (56.2% vs. 37.5%; = 0.0011), experienced longer operating room (OR) time (142 vs. 133; = 0.0201) and length of stay (3.7 vs. 3.1; = 0.0003), and had higher implant and total in-hospital costs ( < 0.0001 and 0.0001). Multivariate linear regression showed implant cost (0.700; < 0.0001), length of stay (0.546; < 0.0001), and OR time (0.288; < 0.0001) to be the strongest associations with overall costs. Primary TJA for nonagenarians was more expensive than octogenarians. Targeting implant costs, length of stay, and OR time can reduce costs for nonagenarians in order to provide cost-effective value-based care.
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http://dx.doi.org/10.3390/geriatrics6010026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006031PMC
March 2021

Out-of-Network Facility Charges for Patients Undergoing Outpatient Total Joint Arthroplasty.

J Arthroplasty 2021 07 5;36(7S):S128-S133. Epub 2021 Mar 5.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA.

Background: The utilization of outpatient (OP) total joint arthroplasty (TJA) is increasing. Although many arthroplasty surgeons and hospitals have longstanding agreements with insurance companies, it may take time for ambulatory surgery centers (ASCs) to establish in-network agreements. The purposes of this study are to investigate trends in out-of-network facility charges for OP-TJA, as well as compare rates of out-of-network facilities between ASC and hospital outpatient department (HOPD) OP-TJA.

Methods: This is a retrospective study of the MarketScan commercial claims database of OP-TJAs (same-day discharge) performed at ASCs or HOPDs from 2007 to 2017. Detailed demographic, geographic, operative, insurance, temporal, and financial details were collected. Out-of-network facility utilization was trended over time. Adjusted regressions compared the prevalence of out-of-network facilities between ASCs and HOPDs.

Results: There were 13,031 OP-TJA patients (58.8% total knee arthroplasty). Utilization of out-of-network facilities significantly decreased over time, from 27.8% of surgeries in 2007 to 9.5% in 2017 (P < .001); however, this was non-linear with a significant increase in 2013-2015 corresponding to rising use of out-of-network ASCs. Patients treated at ASCs were significantly more likely to be out-of-network than those treated at HOPDs (odds ratio 4.88, 95% confidence interval 4.28-5.57, P < .001; odds ratio 7.70, 95% confidence interval 6.42-9.25, P < .001 among the 11,870 patients with in-network surgeons). About 10.4% of patients with in-network surgeons were treated at out-of-network facilities.

Conclusion: Although the utilization of out-of-network facilities has decreased, over 10% of patients with in-network surgeons face out-of-network facility charges, which may often come as a surprise. Efforts are warranted to reduce the out-of-network facility burden for OP-TJA patients, including accelerating insurance contracting and reviewing patients' coverage statuses.
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http://dx.doi.org/10.1016/j.arth.2021.03.001DOI Listing
July 2021
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