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Patient Perception of Reimbursement for Arthroscopic Meniscectomy and ACL Reconstruction
ABSTRACTS
Methods: 531 consecutive knees with contained focal chondral lesions treated with microfracture by a single surgeon were studied. Lesions were on femoral condyles, tibial plateaus, or patellofemoral joints. Lesion size was measured and documented at index surgery. Groups were based on lesion size: Group I¼25 to <200 mm2, Group II¼200 to<400 mm2, Group III¼400 to 600 mm2. Microfracture technique was previously published. Outcomes measures included SF12, Lysholm function, Tegner activity, and patient satisfaction (0¼ dissatisfied, 10¼totally satisfied). Results: At average 9.7 years followup (range 2 to 22 years), 386 knees had tibiofemoral lesions and 144 had patellofemoral lesions. Tibiofemoral lesions showed no significant differences in outcomes regardless of size. Lesion size did not correlate with age or any outcomes measure except satisfaction (rho¼-0.114;p¼0.048) and Tegner (rho¼0.110;p¼0.048). Age correlated with Tegner (rho¼0.133;p¼0.032), previously shown in normal knees and other studies. Patellofemoral lesions showed no significant differences in outcome scores regardless of size. Size correlated with age (rho¼0.191;p¼0.04) but not with any outcomes score. Conclusion: Lesion size at index microfracture had no effect on function (Lysholm), activity level (Tegner) or patient satisfaction. Findings were consistent regardless of lesion location. In this large patient group, contained lesion size did not influence outcome. Lesion size should not deter using microfracture as the first choice treatment.
Does Knee Arthroscopy for Treatment of Meniscal Damage with Osteoarthritis “Buy Patients Time” to Knee Replacement Compared to PT Alone? SS-59 April 16, 1:20 PM RONALD NAVARRO, M.D., PRESENTING AUTHOR ANNETTE ADAMS, PH.D. JOHN FLEMING, M.D. IVAN GARCIA, M.D. MARY HELEN BLACK, PH.D. Introduction: Our aims were to determine differences in clinical outcomes for Knee Arthroscopy (KA) vs. Physical Therapy (PT) only with knee replacement as endppoint. Methods: The cohort is comprised of patients aged >45 years, with >2 years membership, no prior knee surgery and recent history of OA at the time of meniscal tear diagnosis (2003-2006). Patients were followed from date of surgery (KA) or first PT visit (PT-only) until partial/total knee replacement surgery, death, disenrollment, or end of study (12/31/2013), whichever occurred first. Cox proportional hazards and robust Poisson models were used to estimate the risk of knee replacement surgery and greater utilization/medication use, respectively, associated with KA vs. PT-alone. Demographic/clinical characteristics were used to derive a propensity score, and inverse probability of treatment weights applied to individual observations in the estimation of model parameters.
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Results: Among 7,026 patients (69% KA, 31% PT-only), 27% had partial/total knee replacement surgery during follow-up.PT-only patients were older and more likely to be female, have greater comorbidity and utilize health services more frequently, than patients with KA. After accounting for differences between groups, KA patients were no better off than PT-only patients in terms of time to knee replacement surgery; cumulative incidence of knee surgery was significantly higher for those who received KA vs. PT-only (HR:1.30 (95%CI: 1.16-1.46)). No differences in utilization for knee pain, narcotic medication dispenses or knee injections were observed between the groups. Conclusion: For patients with meniscal damage complicated by OA, treatment with KA does not decrease risk for eventual knee replacement compared to PT-alone (did not “buy time”). In fact patients who had KA were 30% more likely to have partial/total knee replacement surgery at any given time than those who had PT-alone. Considering initiatives like Choosing Wisely and organizational goals, reduction in KA procedures performed for these patients may be warranted. Patient Perception of Reimbursement for Arthroscopic Meniscectomy and ACL Reconstruction SS-60 April 16, 1:55 PM KELECHI OKOROHA, M.D., PRESENTING AUTHOR ROBERT KELLER, M.D. NATHAN MARSHALL, M.D. JOHN-MICHAEL GUEST, M.D. JONATHAN LYNCH, M.D. TERRENCE LOCK, M.D. BRAIN RILL, M.D. Introduction: Healthcare policy changes and decreases in Medicare physician reimbursement continue to change the landscape of healthcare. Patient perception of physician reimbursement historically has been exaggerated. However, there is limited evidence of patient perceptions for arthroscopic meniscectomy and ACL reconstruction. This study evaluates patient perceptions of physician reimbursement for arthroscopic meniscectomy and ACL reconstruction and compares perceptions between urban and suburban clinics. Methods: Surveys were given to 231 patients, 127 in an urban and 104 in a suburban clinic. Patients were asked about their estimation of physician reimbursement as well as Medicare reimbursement for arthroscopic meniscectomy and ACL reconstruction. They were also asked how much they would be willing to pay out of pocket for the procedures. After revealing actual reimbursement rates, patients were asked if reimbursement levels were appropriate and additional questions on health care reform. Results: Patients on average believed for a meniscectomy and ACL reconstruction surgeons should receive $8,096 and $11,794 and that Medicare paid physicians $5,442 and $6,667 respectively. Patients were willing to pay $2,286 out of pocket for a meniscectomy and $11,793 for
e26
ABSTRACTS
an ACL reconstruction. Sixty five and fifty seven percent of patients believed reimbursement for meniscectomy and ACL reconstruction was too low respectively. Less than 2% of patients believed physician salaries should be cut, whereas 75% believed physicians should be paid extra for sub-specialty training. There were no differences in payment perception between urban and suburban settings. Conclusion: Patients perceived the values of meniscectomy and ACL reconstruction were substantially higher than current Medicare reimbursement. The majority of patients believed that the current reimbursement is too low and patients on average would be willing to pay more out of pocket than is currently reimbursed. Continued decreases in Medicare reimbursements without account of patient values may force physician’s to decline certain insurances, creating a potential for decreased medical access.
Clinical Outcomes and Failure Rate of Anterior Cruciate Ligament Reconstruction Using Autograft Hamstring Versus a Hybridgraft SS-61 April 16, 2:00 PM BRIAN LEO, M.D., PRESENTING AUTHOR ANDRES ALVAREZ-PINZON, M.D., PH.D. MICHAEL KRILL, B.S. LETICIA BARKSDALE, M.D. Introduction: Compare and report the outcomes of the re-rupture rate of isolated ACL reconstruction using autograft hamstring and a soft tissue hybrid graft. Methods: Prospective, single-center, comparative-study of subjects who underwent arthroscopic reconstruction of the ACL with autograft-hamstring or a soft tissue hybrid-graft. Patients with isolated ACL tears were included and underwent anatomic single-bundle reconstruction utilizing an independent tunnel drilling-technique and had at least 24-months follow-up. The primary outcome assessed was the presence or absence of ACL re-rupture. Secondary clinical outcomes consisted of the International Knee Documentation committee(IKDC), UCLA-ACL-QL evaluations and the Visual Analog Scale-(VAS). Results: Between February-2010 and April-2013 ninetyfive patients between ages 18-40 were enrolled. 71 autograft hamstring and 24 soft tissue hybrid graft ACL reconstructions. Follow-up period was 24 to 32 months (mean 26.9 months). There were no statistically significant differences in patient demographics or Outerbridge classification. No statistically significant differences in ACL retears (4.2%, 6.15%; p¼0.57) between groups. Clinical IKDC and UCLA ACL-QL improvement scores revealed no statistically significant differences in autograft and hybrid graft (41.1 11.6; 42.9 13.6; p¼0.65), (31.8 9.9; 31.5 11.1; p¼0.37). The mean pain level decreased from 7.9 to 3.1 in autograft group and 6.8 to 1.9 in the hybrid group (p¼0.124).
Conclusion: The use of a hybrid graft in a young, active population is comparable to ACL reconstruction utilizing the gold standard-autograft hamstring. Surgeons can feel confident using hybrid soft tissue grafts for planned primary ACL reconstruction or as an alternative graft in cases where insufficient size hamstring call for allograft augmentation. All-Epiphyseal ACL Reconstruction in Children: Review of Safety and Early Complications SS-62 April 16, 2:05 PM ARISTIDES CRUZ JR., M.D., PRESENTING AUTHOR PETER FABRICANT, M.D., M.P.H. MICHAEL MCGRAW, M.D. JOSHUA ROZELL, M.D. THEODORE GANLEY, M.D. LAWRENCE WELLS, M.D. Introduction: There are several described techniques for “physeal respecting” ACL reconstruction. Techniques continue to be refined, however, there is a paucity of literature that directly evaluates there safety . The purpose of this study is to elucidate the complication rate and identify associated risk factors for re-rupture after all epiphyseal anterior cruciate ligament reconstruction in children. Methods: We retrospectively reviewed patients who underwent all-epiphyseal ACL reconstructions performed at a large, tertiary care children’s hospital between January 2007 and April 2013. Relevant postoperative data including the development of leg length discrepancy, angular deformity, rerupture, infection, knee range of motion, arthrofibrosis, and other complications were recorded. Independent variables analyzed for association with re-rupture included age, BMI, graft type, graft size, and associated injuries addressed at surgery. Results: 103 patients (average 12.1 years old, range: 6.315.7) were analyzed. Mean follow-up was 21 months. The overall complication rate was 16.5% (17/103), including 11 re-ruptures (10.7%), 1 case (<1.0%) of clinical leg length discrepancy of <1 cm and 2 cases (1.9%) of arthrofibrosis requiring manipulation under anesthesia. Two patients (1.9%) sustained contralateral ACL ruptures and 3 (2.9%) sustained ipsilateral meniscus tears during the study period. There were no associations found between age, sex, graft type, graft thickness, BMI, or associated injuries addressed during surgery and rerupture rate. Knee flexion continued to improve by 20 degrees on average between the 6 week and 6 month post-operative visits (P<0.001; paired samples Student’s t-test). Conclusion: All-epiphyseal ACL reconstruction in children is safe. The rate of growth disturbance in this study is similar to previous reports in this patient demographic. The re-rupture rate in this pediatric cohort is slightly higher compared to ACL reconstruction in older patients.
Methods: 531 consecutive knees with contained focal chondral lesions treated with microfracture by a single surgeon were studied. Lesions were on femoral condyles, tibial plateaus, or patellofemoral joints. Lesion size was measured and documented at index surgery. Groups were based on lesion size: Group I¼25 to <200 mm2, Group II¼200 to<400 mm2, Group III¼400 to 600 mm2. Microfracture technique was previously published. Outcomes measures included SF12, Lysholm function, Tegner activity, and patient satisfaction (0¼ dissatisfied, 10¼totally satisfied). Results: At average 9.7 years followup (range 2 to 22 years), 386 knees had tibiofemoral lesions and 144 had patellofemoral lesions. Tibiofemoral lesions showed no significant differences in outcomes regardless of size. Lesion size did not correlate with age or any outcomes measure except satisfaction (rho¼-0.114;p¼0.048) and Tegner (rho¼0.110;p¼0.048). Age correlated with Tegner (rho¼0.133;p¼0.032), previously shown in normal knees and other studies. Patellofemoral lesions showed no significant differences in outcome scores regardless of size. Size correlated with age (rho¼0.191;p¼0.04) but not with any outcomes score. Conclusion: Lesion size at index microfracture had no effect on function (Lysholm), activity level (Tegner) or patient satisfaction. Findings were consistent regardless of lesion location. In this large patient group, contained lesion size did not influence outcome. Lesion size should not deter using microfracture as the first choice treatment.
Does Knee Arthroscopy for Treatment of Meniscal Damage with Osteoarthritis “Buy Patients Time” to Knee Replacement Compared to PT Alone? SS-59 April 16, 1:20 PM RONALD NAVARRO, M.D., PRESENTING AUTHOR ANNETTE ADAMS, PH.D. JOHN FLEMING, M.D. IVAN GARCIA, M.D. MARY HELEN BLACK, PH.D. Introduction: Our aims were to determine differences in clinical outcomes for Knee Arthroscopy (KA) vs. Physical Therapy (PT) only with knee replacement as endppoint. Methods: The cohort is comprised of patients aged >45 years, with >2 years membership, no prior knee surgery and recent history of OA at the time of meniscal tear diagnosis (2003-2006). Patients were followed from date of surgery (KA) or first PT visit (PT-only) until partial/total knee replacement surgery, death, disenrollment, or end of study (12/31/2013), whichever occurred first. Cox proportional hazards and robust Poisson models were used to estimate the risk of knee replacement surgery and greater utilization/medication use, respectively, associated with KA vs. PT-alone. Demographic/clinical characteristics were used to derive a propensity score, and inverse probability of treatment weights applied to individual observations in the estimation of model parameters.
e25
Results: Among 7,026 patients (69% KA, 31% PT-only), 27% had partial/total knee replacement surgery during follow-up.PT-only patients were older and more likely to be female, have greater comorbidity and utilize health services more frequently, than patients with KA. After accounting for differences between groups, KA patients were no better off than PT-only patients in terms of time to knee replacement surgery; cumulative incidence of knee surgery was significantly higher for those who received KA vs. PT-only (HR:1.30 (95%CI: 1.16-1.46)). No differences in utilization for knee pain, narcotic medication dispenses or knee injections were observed between the groups. Conclusion: For patients with meniscal damage complicated by OA, treatment with KA does not decrease risk for eventual knee replacement compared to PT-alone (did not “buy time”). In fact patients who had KA were 30% more likely to have partial/total knee replacement surgery at any given time than those who had PT-alone. Considering initiatives like Choosing Wisely and organizational goals, reduction in KA procedures performed for these patients may be warranted. Patient Perception of Reimbursement for Arthroscopic Meniscectomy and ACL Reconstruction SS-60 April 16, 1:55 PM KELECHI OKOROHA, M.D., PRESENTING AUTHOR ROBERT KELLER, M.D. NATHAN MARSHALL, M.D. JOHN-MICHAEL GUEST, M.D. JONATHAN LYNCH, M.D. TERRENCE LOCK, M.D. BRAIN RILL, M.D. Introduction: Healthcare policy changes and decreases in Medicare physician reimbursement continue to change the landscape of healthcare. Patient perception of physician reimbursement historically has been exaggerated. However, there is limited evidence of patient perceptions for arthroscopic meniscectomy and ACL reconstruction. This study evaluates patient perceptions of physician reimbursement for arthroscopic meniscectomy and ACL reconstruction and compares perceptions between urban and suburban clinics. Methods: Surveys were given to 231 patients, 127 in an urban and 104 in a suburban clinic. Patients were asked about their estimation of physician reimbursement as well as Medicare reimbursement for arthroscopic meniscectomy and ACL reconstruction. They were also asked how much they would be willing to pay out of pocket for the procedures. After revealing actual reimbursement rates, patients were asked if reimbursement levels were appropriate and additional questions on health care reform. Results: Patients on average believed for a meniscectomy and ACL reconstruction surgeons should receive $8,096 and $11,794 and that Medicare paid physicians $5,442 and $6,667 respectively. Patients were willing to pay $2,286 out of pocket for a meniscectomy and $11,793 for
e26
ABSTRACTS
an ACL reconstruction. Sixty five and fifty seven percent of patients believed reimbursement for meniscectomy and ACL reconstruction was too low respectively. Less than 2% of patients believed physician salaries should be cut, whereas 75% believed physicians should be paid extra for sub-specialty training. There were no differences in payment perception between urban and suburban settings. Conclusion: Patients perceived the values of meniscectomy and ACL reconstruction were substantially higher than current Medicare reimbursement. The majority of patients believed that the current reimbursement is too low and patients on average would be willing to pay more out of pocket than is currently reimbursed. Continued decreases in Medicare reimbursements without account of patient values may force physician’s to decline certain insurances, creating a potential for decreased medical access.
Clinical Outcomes and Failure Rate of Anterior Cruciate Ligament Reconstruction Using Autograft Hamstring Versus a Hybridgraft SS-61 April 16, 2:00 PM BRIAN LEO, M.D., PRESENTING AUTHOR ANDRES ALVAREZ-PINZON, M.D., PH.D. MICHAEL KRILL, B.S. LETICIA BARKSDALE, M.D. Introduction: Compare and report the outcomes of the re-rupture rate of isolated ACL reconstruction using autograft hamstring and a soft tissue hybrid graft. Methods: Prospective, single-center, comparative-study of subjects who underwent arthroscopic reconstruction of the ACL with autograft-hamstring or a soft tissue hybrid-graft. Patients with isolated ACL tears were included and underwent anatomic single-bundle reconstruction utilizing an independent tunnel drilling-technique and had at least 24-months follow-up. The primary outcome assessed was the presence or absence of ACL re-rupture. Secondary clinical outcomes consisted of the International Knee Documentation committee(IKDC), UCLA-ACL-QL evaluations and the Visual Analog Scale-(VAS). Results: Between February-2010 and April-2013 ninetyfive patients between ages 18-40 were enrolled. 71 autograft hamstring and 24 soft tissue hybrid graft ACL reconstructions. Follow-up period was 24 to 32 months (mean 26.9 months). There were no statistically significant differences in patient demographics or Outerbridge classification. No statistically significant differences in ACL retears (4.2%, 6.15%; p¼0.57) between groups. Clinical IKDC and UCLA ACL-QL improvement scores revealed no statistically significant differences in autograft and hybrid graft (41.1 11.6; 42.9 13.6; p¼0.65), (31.8 9.9; 31.5 11.1; p¼0.37). The mean pain level decreased from 7.9 to 3.1 in autograft group and 6.8 to 1.9 in the hybrid group (p¼0.124).
Conclusion: The use of a hybrid graft in a young, active population is comparable to ACL reconstruction utilizing the gold standard-autograft hamstring. Surgeons can feel confident using hybrid soft tissue grafts for planned primary ACL reconstruction or as an alternative graft in cases where insufficient size hamstring call for allograft augmentation. All-Epiphyseal ACL Reconstruction in Children: Review of Safety and Early Complications SS-62 April 16, 2:05 PM ARISTIDES CRUZ JR., M.D., PRESENTING AUTHOR PETER FABRICANT, M.D., M.P.H. MICHAEL MCGRAW, M.D. JOSHUA ROZELL, M.D. THEODORE GANLEY, M.D. LAWRENCE WELLS, M.D. Introduction: There are several described techniques for “physeal respecting” ACL reconstruction. Techniques continue to be refined, however, there is a paucity of literature that directly evaluates there safety . The purpose of this study is to elucidate the complication rate and identify associated risk factors for re-rupture after all epiphyseal anterior cruciate ligament reconstruction in children. Methods: We retrospectively reviewed patients who underwent all-epiphyseal ACL reconstructions performed at a large, tertiary care children’s hospital between January 2007 and April 2013. Relevant postoperative data including the development of leg length discrepancy, angular deformity, rerupture, infection, knee range of motion, arthrofibrosis, and other complications were recorded. Independent variables analyzed for association with re-rupture included age, BMI, graft type, graft size, and associated injuries addressed at surgery. Results: 103 patients (average 12.1 years old, range: 6.315.7) were analyzed. Mean follow-up was 21 months. The overall complication rate was 16.5% (17/103), including 11 re-ruptures (10.7%), 1 case (<1.0%) of clinical leg length discrepancy of <1 cm and 2 cases (1.9%) of arthrofibrosis requiring manipulation under anesthesia. Two patients (1.9%) sustained contralateral ACL ruptures and 3 (2.9%) sustained ipsilateral meniscus tears during the study period. There were no associations found between age, sex, graft type, graft thickness, BMI, or associated injuries addressed during surgery and rerupture rate. Knee flexion continued to improve by 20 degrees on average between the 6 week and 6 month post-operative visits (P<0.001; paired samples Student’s t-test). Conclusion: All-epiphyseal ACL reconstruction in children is safe. The rate of growth disturbance in this study is similar to previous reports in this patient demographic. The re-rupture rate in this pediatric cohort is slightly higher compared to ACL reconstruction in older patients.