American Academy of Orthopaedic Surgeons Annual Meeting
American Academy of Orthopaedic Surgeons Annual Meeting
April 15, 2019
2 min read

Speaker: Health-status improvement program can aid success in alternative payment models

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LAS VEGAS — Results of a program that identifies and optimizes patients with risk factors associated with a poor outcome after total joint arthroplasty and delays their surgery until those factors are modified showed reduced 30- and 90-day readmission rates compared to readmission in patients whose risk factors were not optimized, according to presenter at The Hip Society Specialty Day at the American Academy of Orthopaedic Surgeons Annual Meeting, here.

Richard Iorio, MD, said delaying surgery in patients who needed certain risk factors modified before they underwent TJA helped NYU Langone Health improve its quality metrics. Therefore, this approach may help other hospitals and joint replacement programs be successful in the quality joint replacement programs in which they participate, he said.

Iorio, who is now at Brigham and Women’s Hospital in Boston, said surgeon-directed risk factor stratification and modification programs to delay surgery are complicated and require multidisciplinary input. Therefore, NYU Langone Health hired a risk stratification coordinator to handle its program and Brigham and Women’s Hospital followed suit.

“In the end, when the physicians and the hospitals work together on these resources, you can change the quality metric associated with your patient population,” Iorio said.

In discussing the NYU program, Iorio said simply changing or modifying patients’ risk factors was not enough. He and his colleagues needed to analyze its impact on readmissions, which is an area that can positively affect the cost savings that is sought in today’s alternative payment models.

By not operating on their high-risk patients in the Medicare population, orthopedic surgeons at NYU Langone Health reduced readmission rates from about 15% to less than 5%. However, this left many Medicare patients who still needed joint replacement surgery. Therefore, Iorio and his colleagues wondered what patients’ outcomes would be if they were delayed, optimized and then underwent surgery.

To study this, 1,000 patients with an American Society of Anesthesiologists score of 3 or more, meaning they were high risk or would likely have readmission rates that were two- to six-times higher than usual, were either optimized or not optimized. For both groups, investigators looked at such factors the 30-, 60- and 90-day readmissions, length of stay, discharge disposition and infection rates, Iorio said.

“When you look at these statistics, the optimized patients did better on almost all of the quality metrics and we were able to show also improvement in their performance. We were able to reduce 30- and 90-day readmission rates. We were able to change infection rates,” he said.


“The cost was significantly less in this population after it was optimized,” Iorio said when he presented data that showed how much the target prices were moved downward as a result of the program.

“They approach 90-day [diagnosis-related group] DRG prices. These types of programs are going to be necessary to be successful in these alternative payment paradigms. So, the identification and medical optimization of these comorbidities, prior to surgical intervention, is critical if you want to be successful in a quality program,” he said. – by Susan M. Rapp



Iorio R. Modifying risk factors. Presented at: Hip Society Specialty Day at the American Academy of Orthopaedic Surgeons Annual Meeting; March 16, 2019; Las Vegas.


Disclosure: Iorio reports he has stock or stock options with Force Therapeutics, is a paid consultant for Johnson & Johnson, is a paid consultant for and has stock or stock options with MedTel, is a paid consultant for Medtronic, is a paid consultant for and has stock or stock options with Muve Health, is a paid consultant for Pacira, is a paid consultant for Recro Pharma, has stock or stock options with URX Mobile and Wellbe, and is a paid consultant for Zimmer Biomet.