Holle, Alejandro

» Affordable Care Act Medicaid expansion increased orthopaedic surgery access and utilization among Medicaid patients, including for racial and ethnic minorities. » Despite improved coverage, Medicaid patients continue to face significant real-world barriers to orthopaedic care, including lower appointment success and longer wait times compared with privately insured patients. » Evidence on cost and quality impacts remains limited, with early signals of increased reimbursements, higher charges, and some quality improvements postexpansion.

Background: The Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) has undergone numerous changes to promote care for patients at high social risk. However, the effect of these changes on surgeon MIPS performance and caseload selection remains unclear. Thus, the purpose of this study was to evaluate how orthopaedic surgeon MIPS scores, demographics, practice characteristics, and patient populations varied on the basis of patient social risk in 2017 compared with 2021. Methods: CMS data were utilized to examine U.S. orthopaedic surgeons. Surgeons were placed into social-risk quintiles on the basis of the proportion of their patients who were dually eligible for Medicare and Medicaid, with the highest quintile representing the highest social risk. Demographics, practice location characteristics, patient data, and MIPS performance were assessed for the years 2017 and 2021. Differences between social-risk quintiles were assessed utilizing chi-square, Student t, and Wilcoxon signed-rank tests and multivariable logistic regression. Results: In 2017, surgeons with caseloads at the highest, compared with the lowest, social risk had lower MIPS performance scores (mean [and standard deviation], 66.0 ± 37.6 versus 70.1 ± 33.5; p < 0.001). However, in 2021, orthopaedic surgeons with caseloads at the highest, compared with the lowest, social risk had significantly higher MIPS performance scores (mean, 88.7 ± 16.9 versus 81.5 ± 18.3; p < 0.001). In terms of demographics, in 2021, orthopaedic surgeons with caseloads at the highest, compared with the lowest, social risk were more often women (9.2% versus 3.6%; p < 0.001), more often had a DO degree (11.2% versus 6.6%; p < 0.001), more recently graduated from medical school (mean, 23.0 ± 12.9 versus 25.7 ± 10.9 years; p < 0.001), and worked in areas with higher Distressed Communities Index (DCI) distress scores (mean, 56.9 ± 27.3 versus 35.1 ± 25.2; p < 0.001). Similar findings were present in 2017. Conclusions: The addition of the Complex Patient Bonus to the MIPS in 2020 may have reduced performance inequities in MIPS scoring for surgeons with caseloads at high social risk. However, the demographics and practice patterns of the orthopaedic surgeons caring for populations at the highest social risk remained consistent between years. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: There has been minimal literature evaluating how a prior myocardial infraction (MI) influences outcomes after total knee arthroplasty (TKA). Thus, the purpose of this study was to evaluate how the timing, type, and treatment of MI prior to TKA affect postoperative cardiac complications, general medical complications, and surgical complications. Methods: A retrospective comparative study was conducted using a large insurance database. Patients undergoing primary TKA for osteoarthritis were included. Patients who had experienced MI within 2 years before TKA were identified and were matched 1:4 with patients who had not had such an MI on the basis of demographic variables and comorbidities. Patients who had a prior MI were stratified into 4 groups based on the timing of the MI: 0 to <6 months, 6 to <12 months, 12 to <18 months, and 18 to 24 months before TKA. The rates of postoperative cardiac, general medical, and surgical complications were compared between groups. Subanalyses on the prior MI type, treatment, and location were performed. Results: Prior MI was associated with increased risks of postoperative MI (odds ratio [OR], 3.97 [95% confidence interval (CI), 3.20 to 4.93]), heart failure (OR, 1.45 [95% CI, 1.24 to 1.75]), and 90-day mortality (OR, 2.15 [95% CI, 1.41 to 3.28]). The risk of postoperative MI was highest for those with MI within 6 months before TKA (OR, 6.86 [95% CI, 5.34 to 8.82]). Type-1 MI, ST-elevation MI (STEMI), non-ST-elevation MI (NSTEMI), and anterior and inferior MIs were linked to elevated postoperative MI and/or mortality risks, with timing closer to surgery further amplifying the risk. Percutaneous coronary intervention within 6 months before TKA also increased postoperative risks. Type-2 MI within 6 months before TKA was associated with an increased risk of periprosthetic joint infection compared with controls (OR, 4.23 [95% CI, 1.67 to 10.67]). Conclusions: Patients who had a prior MI, particularly within 6 months before TKA, had significantly elevated risks of postoperative MI, heart failure, and mortality. Outcomes varied by MI type, treatment, and location, with type-1 MIs and STEMIs increasing the postoperative mortality risk. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Purpose To evaluate which patient factors are associated with specific metrics of poor access to care in patients with a rotator cuff tear (RCT). Methods The All of Us Database was utilized to form a cohort of patients with RCT between May 2018 and May 2023. Patients with a diagnosis of RCT using Systematized Nomenclature of Medicine clinical terms were included. The association of RCT diagnosis and patient‐specific factors on self‐reported outcomes of “delayed care,” “could not afford care,” “skipped medication,” and “have not seen provider in more than 1 year” were analyzed. Statistical tests performed were univariate regression and multivariable logistic regression. Results In total, 4,265 patients with RCT who completed the access to care survey were included. In the RCT cohort, 26.7% reported delayed care, 24.9% reported an inability to afford care, 12.1% reported skipped medications, and 1.7% reported not seeing a provider in more than 1 year. Multivariable analysis of patient treatment and demographic features revealed younger age, female sex, lower income, poor physical health, and poor mental health to be strongly associated with higher reported rates of delayed care, inability to afford care, and skipped medications. History of rotator cuff repair, marital status, and sexual orientation were not associated with reported poor access to care. Conclusions A quarter of patients with rotator cuff tears report delays in overall medical care and inability to afford care. Among patients diagnosed with RCT, patients of younger age, female sex, low income, and poor physical and mental health have higher odds of decreased access to health care. Clinical Relevance Health care disparities and access to care are topics that should be investigated to reduce them.

Background: The purpose of this study was to investigate the association between cannabis use and postoperative complications following ankle and hindfoot arthrodesis. Methods: A retrospective cohort study using a large national insurance database from 2010 to 2022 was conducted. All patients who underwent ankle or hindfoot arthrodesis with at least 2 years’ follow-up were included. Patients were divided into 4 groups: cannabis-only users, tobacco-only users, cannabis and tobacco users, and nonuser controls. Groups were matched 1:4 with nonuser controls based on demographic variables and comorbidities. Also, both cannabis and tobacco users were matched 1:4 with tobacco-only users based on demographics and comorbidities. Medical complications within 90 days of surgery and surgery-specific complications within 2 years were compared between groups with multivariable logistic regressions. Results: Compared with nonuser controls, cannabis users only were not at increased risk of 90-day medical complications or 2-year surgical complications. Tobacco use alone was associated with increased risk of postoperative admission (OR 1.32, 95% CI 1.21-1.43) and emergency department (ED) utilization (OR 1.57, 95% CI 1.48-1.66) within 90 days as well as infection (OR 1.24, 95% CI 1.18-1.30), hardware removal (OR 1.12, 95% CI 1.07-1.18), nonunion (OR 1.33, 95% CI 1.27-1.40), and wound dehiscence (OR 1.38, 95% CI 1.27-1.49) within 2 years of surgery compared with nonuser controls. Compared with tobacco-only use, combined cannabis and tobacco use was associated with increased risk of ED visits within 90 days (OR 1.45, 95% CI 1.30-1.62) and nonunion within 2 years of surgery (OR 1.19, 95% CI 1.05-1.35). Conclusion: These findings suggest that although cannabis use alone was not associated with a higher risk of postoperative complications, its concurrent use with tobacco was linked to greater rates of adverse outcomes. Level of Evidence: Level III, retrospective case control study.

Background: Tobacco use is a known modifiable risk factor for postoperative complications and revision surgery after anterior cruciate ligament reconstruction (ACLR). Previous studies focus on tobacco as a broad categorization of traditional smoking, smokeless tobacco, and other forms of nicotine use. It is unclear if differences in the type of nicotine used lead to similar adverse outcomes after ACLR. Purposes: To (1) assess the incidence of postoperative complications among ACLR patients who use smokeless tobacco and (2) compare these outcomes with those of patients who do not use tobacco and those who smoke tobacco. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study utilizing the PearlDiver database was conducted. Patients undergoing primary ACLR with a minimum 2-year follow-up were included. Smokeless tobacco users (n = 898), cigarette smokers (n= 22,062), and non–tobacco users (n= 207,462) were matched based on patient variables and comorbidities. Postoperative complications within 90 days of surgery and subsequent knee surgery within 2 years were compared among groups. Multivariable logistic regressions were used to control for confounding variables. Results: Compared with nonusers, smokeless tobacco users demonstrated an increased risk of pneumonia (odds ratio [OR], 3.36; 95% CI, 1.41-7.90), acute kidney injury (OR, 12.7; 95% CI, 3.77-52.8), and emergency department (ED) utilization (OR, 6.29; 95% CI, 3.70-10.9) within 90 days of the ACLR. Additionally, smokeless tobacco users had an increased risk of ACLR (OR, 4.75; 95% CI, 3.60-6.26) and meniscal surgery (OR, 2.89; 95% CI, 2.23-3.73) within 2 years. When compared with cigarette smokers, smokeless tobacco users showed an increased risk of pneumonia (OR, 3.25; 95% CI, 1.33-7.78), acute kidney injury (OR, 7.63; 95% CI, 2.72-22.5), and ED visits (OR, 1.55; 95% CI, 1.26-1.90) within 90 days and subsequent ACLR (OR, 4.81; 95% CI, 3.58-6.47) and meniscal surgery (OR, 3.23; 95% CI, 2.45-4.26) within 2 years. Conclusion: Smokeless tobacco use was associated with an increased risk of medical complications, ED utilization, and subsequent procedures compared with nonuser controls and traditional smokers. These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR.

Background Value-based care payment and delivery models such as the recently implemented Merit-based Incentive Payment System (MIPS) aim to both provide better care for patients and reduce costs of care. Gender disparities across orthopaedic surgery, encompassing reimbursement, industry payments, referrals, and patient perception, have been thoroughly studied over the years, with numerous disparities identified. However, differences in MIPS performance based on orthopaedic surgeon gender have not been comprehensively evaluated. Questions/purposes After controlling for potentially confounding variables such as experience, geography, group size, and Medicare beneficiary characteristics, does MIPS performance differ between men and women orthopaedic surgeons? Methods The Medicare Physician and Other Practitioners and the Physician Compare databases were queried for years 2017, the first year MIPS was incorporated, and 2021, the most recent year with MIPS data published, to identify all physicians with a self-reported specialty of orthopaedic surgery. Together, these databases include all physicians who submitted at least 11 Medicare claims each year. Physician gender, US census region, years in practice, group practice size, billing practices, and patient demographic characteristics were collected for each surgeon. The MIPS Performance database was used to extract an overall MIPS performance score for each surgeon for each year. Payment adjustments, which are determined based on overall MIPS performance score, were derived for each surgeon based on the thresholds published by the Centers for Medicare & Medicaid Services. Payment adjustments include a negative adjustment, neutral adjustment, positive adjustment, or exceptional performance bonus and are associated with different thresholds each year. Statistical differences based on surgeon gender were assessed utilizing chi-square tests for categorical data, Student t-test for parametric continuous data, and Wilcoxon signed-rank test for nonparametric continuous data. Univariable and multivariable analyses were performed to analyze the relationship between surgeon gender and MIPS performance. Results After controlling for other patient and surgeon variables, woman gender was associated with a slightly increased MIPS performance score in 2021 (β 1.5 [95% confidence interval (CI) 0.02 to 3.00]; p = 0.047). However, this finding was statistically fragile, with the lower bound 95% CI being very close to the line of no difference. No association between surgeon gender and MIPS performance score was found in 2017 (β 2.2 [95% CI -0.5 to 4.9]; p = 0.11). Additionally, no relationship was found between gender and receiving either an exceptional performance MIPS bonus or a MIPS penalty in either year. Conclusion Women orthopaedic surgeons scored slightly higher on the MIPS in 2021, after controlling for surgeon and patient variables, despite providing care for a higher percentage of dual Medicare-Medicaid eligible patients and more medically complex patients. However, this finding was statistically fragile, with a small effect size, a 95% CI close to 0, and no consistent association in MIPS performance in 2017. Additionally, with no differences in MIPS performance bonuses or penalties, the clinical monetary impact of this difference may be minimal. Clinical Relevance The observed association between surgeon gender and MIPS performance scores in 2021, with women orthopaedic surgeons achieving slightly higher scores, raises interesting questions about potential differences in practice behaviors, communication styles, care quality, or other unmeasured variables. These findings may reflect true differences in how care is delivered or documented as scored by the MIPS. However, given the small effect size, statistical fragility, and inconsistency across years, there is a chance that this finding may be spurious. That being so, future research should aim to validate or refute these findings by examining a broader range of variables including documentation practices, practice behaviors, institutional differences, potential systemic biases in scoring methodologies, and patient outcomes. Understanding whether these differences are true is important to ensure that performance metrics like MIPS accurately and equitably reflect care quality.

Purpose To characterize the relationship between testosterone replacement therapy (TRT) and anterior cruciate ligament (ACL) injuries. Methods A retrospective cohort study using a large insurance database was conducted. Patients who were prescribed TRT for at least 3 months were matched with controls who were not prescribed TRT. Rates of ACL tears were compared between the cohorts. Multiple subgroups were created based on age (<25, 25‐35, 36‐45, 46‐55, 56‐65, and 65+ years). Multivariable logistic regressions were performed to determine the association of TRT with ACL tears while accounting for demographic variables and comorbidities. Results After matching, there were 160,839 patients in both the TRT cohort and the control cohort. The incidence of ACL injuries was 17.8 per 10,000 person‐years (95% confidence interval [CI]: 16.4‐19.2) for patients who were prescribed TRT and 4.9 per 10,000 person‐years (95% CI: 4.1‐5.7) for controls ( P < .001). Within 2 years of filling a testosterone prescription for at least 3 months, 572 (0.35%) patients experienced an ACL injury compared to only 157 (0.10%) controls during the same follow‐up period (odds ratio: 2.77; 95% CI: 2.26‐3.42, P < .001). When stratified by age, all groups except the <25 years of age group demonstrated a significantly higher rate of ACL tears (odds ratio 3.91‐12.3, P < .001‐.009). When separated by sex, males on TRT were 3.13 (95% CI: 2.50‐3.93, P < .001) times more likely while females on TRT were 1.94 (95% CI: 1.13‐3.41, P = .018) times more likely to experience an ACL injury compared to controls. Conclusions This study found that patients prescribed at least 3 months of TRT had a significantly higher incidence of ACL injuries compared to controls within a 2‐year follow‐up period. Level of Evidence Level III, retrospective comparative study.

Purpose To determine whether long‐term preoperative nonsteroidal anti‐inflammatory drug (NSAID) use affected the revision rates after primary tendon repair for the following common sports medicine surgical procedures: rotator cuff repair (RCR), Achilles tendon repair (ATR), distal biceps repair (DBR), or quadriceps tendon repair (QTR). Methods A retrospective comparative study using a national insurance database was performed. Patients who underwent major tendon repair, including RCR, ATR, DBR, or QTR, with at least 2‐year follow‐up were identified. Those who had a diagnosis of long‐term NSAID use prior to the index operation were identified and matched 1:4 to controls without NSAID use based on age, sex, specific tendon repaired, and Elixhauser Comorbidity Index. The revision repair rates of the 2 groups were compared. Results A total of 36,068 patients underwent major tendon repair. Of these, 7,246 (20%) met the long‐term NSAID use criteria prior to tendon repair (NSAID users). After RCR, 3.2% of NSAID users (n = 190) and 2.6% of controls (n = 617) underwent revision surgery within 2 years (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.97‐1.36; P = .10). After ATR, NSAID users had a revision rate of 3.9% (n = 24) versus 2.5% (n = 62) in the control cohort (OR, 1.47; 95% CI, 0.89‐2.38; P = .12). After DBR, both NSAID users and controls had fewer than 11 revision cases (OR, 1.54; 95% CI, 0.49‐4.16; P = .42). After QTR, the revision rate was 5.9% (n = 30) for NSAID users compared with 4.8% (n = 95) for the control group (OR, 1.22; 95% CI, 0.77‐1.86; P = .38). None of the observed differences in revision rates between NSAID users and controls were significant. Conclusions Patients with a diagnosis of and coding for long‐term preoperative NSAID use do not have greater revision rates within 2 years of primary tendon repair than patients without this diagnosis. Level of Evidence Level III, retrospective case‐control study.