Substantial Preoperative Work Is Unaccounted for in Total Hip and Knee Arthroplasty

• Published in: The Journal of arthroplasty 2020-09, Vol.35 (9), p.2318-2322
• Main Authors: Krueger, Chad A., Austin, Matthew S., Levicoff, Eric A, Saxena, Arjun, Nazarian, David G., Courtney, P. Maxwell
• Format: Article
• Language: English
• Subjects: Aged; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; health policy; Humans; Length of Stay; Medicare; preoperative work; relative value scale update committee; Relative Value Scales; total hip arthroplasty; total knee arthroplasty; United States - epidemiology
• ISSN: 0883-5403; 1532-8406
• DOI: 10.1016/j.arth.2020.04.066

The Centers for Medicare and Medicaid Services has recently designated the codes for total hip and knee arthroplasty as misvalued and has asked the Relative Value Scale Update Committee (RUC) to review the work required to perform these procedures. Although other studies have reported time spent on perioperative and postoperative care, time spent on coordinating and performing preoperative care is not included in current RUC methodology and has yet to be addressed in literature. We prospectively tracked a consecutive series of 438 primary total hip arthroplasty and total knee arthroplasty patients by one of the 5 surgeons over a 3-month period. Each clinical staff member tracked the amount of time to perform each preoperative care task from the last clinic visit until day of surgery. Data were analyzed separately between providers and ancillary medical staff. Although the current RUC review includes 40 minutes of preservice time on the day of surgery, surgeons spent an average of an additional 43.2 minutes while physician assistants and nurse practitioners spent an additional 97.9 minutes per patient on preoperative care prior to that time. Ancillary medical staff spent a mean of 110.2 minutes per patient. The most common tasks include preoperative phone calls, templating and surgical planning, and preoperative patient education classes. Surgeons and advanced practice providers spend nearly 2 hours per arthroplasty patient on preoperative care not accounted for in current RUC methodology. As readmissions, hospital stay, and complication rates continue to decline, Centers for Medicare and Medicaid Services should consider the substantial work required during the preoperative phase to allow for these improved outcomes.