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Objectives To comprehensively review the available literature on prehabilitation and rehabilitation exercise, nutrition, and psychological support interventions for patients with kidney cancer (KC), to summarise the clinically relevant efficacy and cost‐effectiveness of interventions, to expose key knowledge gaps, and to inform future investigations and initiatives. Methods This review was performed according to the per Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) Extension for Scoping Reviews Guidelines. We included randomised controlled trials (RCTs) assessing programmes of prehabilitation or rehabilitation, exercise, psychological support, or nutrition components in patients with KC or KC caregivers from January 2004 to March 2022. Statistically significant positive (SS+) and negative (SS−) results were summarised. Results The systematic search yielded 10 968 records including 18 RCTs, involving 2774 unique subjects, 706 of whom were KC patients/survivors. None included caregivers or assessed cost‐effectiveness. Two interventions were implemented before surgery, one was implemented prior to initiation of systemic therapy, eight were implemented during systemic or radiation therapy, three were implemented after treatment, while implementation time was not specified for four interventions. Conclusion Most (14/18) RCTs involving exercise, nutrition, psychological support, or prehabilitative or rehabilitative programmes for KC performed to date demonstrated SS+ results. The evidence was most robust regarding previously evaluated psychological support, especially mindfulness‐based interventions (9/10 studies demonstrating SS+ improvement in primary outcomes), followed by therapeutically valid exercise with/without psychological support (5/8 RCTs demonstrated efficacy), then nutrition or pharmacological interventions (2/5 demonstrated efficacy). Level 1 evidence supports counselling patients and referral to mindfulness‐based psychological therapy along with physical therapy or physical medicine and rehabilitation, as well as consideration of preoperative carbohydrate drinks. No studies have examined impact on caregivers, or cost‐effectiveness, which are both critical areas for future study.

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.

ImportanceHip fractures present a substantial public health challenge, with projections of more than 500 000 per year by 2040. As such, frailty indices such as the Revised Risk Analysis Index (RAI) and the Modified Five-Item Frailty Index (mFI-5) have been recently investigated as metrics for preoperative risk stratification for these patients.ObjectiveTo understand the accuracy of frailty, as measured by the RAI and the mFI-5, for estimating 30-day mortality following surgically managed hip fractures.Design, Setting, and ParticipantsThis retrospective cross-sectional analysis used the American College of Surgeons’ National Surgical Quality Improvement database. Patients aged 65 years old with surgically managed traumatic hip fracture from 2015 to 2019 were included. Frailty was evaluated using the RAI, a 5-domain scale with 14 weighted variables graded from 0 to 81, and the mFI-5, a 2-domain scale with 5 unweighted variables graded from 0 to 5; for both, a higher score denotes worse frailty. Data collection occurred from May to June 2024.ExposureDiagnosis of hip fracture and undergoing surgical fixation, hemiarthroplasty, or total hip arthroplasty.Main Outcomes and MeasuresThe primary outcome was 30-day mortality. Multivariable regression was conducted to assess the estimating value of frailty scales. Discriminatory accuracy was assessed using a receiver operating characteristic curve and quantified using a C-statistic.ResultsThe cohort consisted of 114 359 patients (70 038 female [69.9%]; median [IQR] age, 84 [77-89] years) with 51 071 prefrail patients (44.7%) according to the mFI-5 and 31 883 very frail patients (27.9%) according to the RAI comprising the largest frailty groups. Increasing frailty status was associated with greater odds ratio (OR) for 30-day mortality for both the mFI-5 (prefrail OR, 1.35 [95% CI, 1.24-1.47]; frail OR, 2.11 [95% CI, 1.94-2.30]; severely frail OR, 3.53 [95% CI, 3.20-3.90]; P &amp;lt; .001 for all) and RAI (normal OR, 1.55 [95% CI, 1.35-1.79]; frail OR, 2.97 [95% CI, 2.59-3.42]; very frail OR, 6.17 [95% CI, 5.38-7.08]; P &amp;lt; .001 for all). The RAI demonstrated superior discriminatory accuracy for 30-day mortality compared with the mFI-5 (area under the receiver operating characteristic curve, 0.73 [95% CI, 0.72-0.73] vs 0.61 [95% CI, 0.60-0.62]; P &amp;lt; .001).Conclusions and RelevanceIn this cross-sectional study of 114 359 patients, the RAI demonstrated superior odds and discriminatory accuracy for estimating 30-day mortality following surgical management of hip fractures. The RAI may be considered as a risk stratification tool for orthopedic surgeons to adjunct surgical planning, thereby reducing postoperative mortality.

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: Solid organ transplant (SOT) recipients are living longer and, consequently, more of them require elective total hip arthroplasty (THA) to restore mobility and improve quality of life. Because these patients are chronically immunosuppressed and often burdened by multiple comorbidities, their peri-operative risk profile may differ substantially from that of the general THA population. This study aimed to evaluate risk factors associated with acute medical and surgical complications, implant survivorship, and overall mortality in patients with a history of SOT who underwent THA. Methods: A total of 173 THA procedures were reviewed in patients with previous SOT. Among them, 64 had undergone liver transplantation (LT), 83 had received renal transplants (RT), and 26 had experienced more than one type of organ transplant (MT). Kaplan–Meier survival analysis was employed to estimate median survival. Complications were examined using univariate analysis through mixed-effects logistic regression, while Cox regression was utilized to assess mortality risk. The median follow-up period extended to 99 months. Results: The proportion of patients experiencing at least one acute medical event was 27% in the LT group, 33% in the RT group, and 38% in the MT group, with no statistically significant difference between groups (p = 0.5). American Society of Anesthesiologists Class (ASA) 4 (Odds Ratio (OR) = 28; p = 0.006) and treatment with bisphosphonates (OR = 2.25; p = 0.03) were associated with higher risk of acute medical complications. Increased age at the time of SOT was linked to a reduced likelihood of surgical complications (OR = 0.94, p = 0.008), as was older age at the time of undergoing THA (OR = 0.92, p = 0.001). The observed rates of reoperation and implant revision were 3% and 1%, respectively. The estimated patient survivorship rates at 1, 5, and 10 years were 98.6, 82, and 58.4%, respectively. Older age at SOT (Hazard Ratio (HR) = 1.06, p < 0.001), at THA (HR = 1.08, p < 0.001), ASA 4 at THA (HR = 7.57, p = 0.02), and atrial fibrillation (AFib) (HR = 3.13, p = 0.02) were associated with higher mortality. Conclusions: ASA 4 and bisphosphonates were associated with a higher risk of acute medical complications, whereas older age was associated with lower surgical complications. Additionally, older age, ASA 4, and AFib were associated with higher mortality.

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 use the All of Us database to investigate barriers to health care access for patients with meniscus tears and to examine how specific demographic, socioeconomic, and health‐related factors independently influence their health care utilization. Methods The National Institutes of Health All of Us database was queried for patient data between March 2017 and March 2023 to form a cohort of patients with meniscal tears. Patients with meniscal tears were identified using Systematized Nomenclature of Medicine clinical terms. All patients with self‐reported meniscus tears were included, with no exclusion criteria to ensure a diverse representation of underrepresented individuals. Patient responses to the “Healthcare Access and Utilization Survey” were analyzed across 4 domains: “delayed care,” “could not afford care,” “skipped medication,” and “have not seen a provider in over one year.” Results In total, 5,671 survey respondents with meniscal tears were included for analysis from a population of 436,000 eligible records. Among them, 27.7% reported delayed care, 23.9% were unable to afford care, 11.8% skipped medication, and 2.0% had not seen a provider in over a year. Patients with annual incomes under $50,000 were more likely to delay care (odds ratio [OR], 1.41; P < .001), be unable to afford care (OR, 1.73; P < .001), or skip medications (OR, 1.79; P < .001). Younger age than the cohort mean of 65.4 years, female sex, and poor physical and mental health were associated with impaired access in at least 1 care domain. Conclusions Over one‐fourth of patients with a diagnosis of meniscus tear who responded to the All of Us “Healthcare Access and Utilization Survey” reported difficulties with access to care across 4 domains, with those of low income, younger age, female sex, and poor mental or physical health experiencing significant barriers to care. Clinical Relevance This research can inform strategies for equitable treatment of meniscal injuries by highlighting disparities in orthopaedic care access and utilization.

Abstract The study of prehabilitation and rehabilitation ([p]rehabilitation) to alleviate the sequelae of bladder cancer and its treatment has generated numerous opportunities to improve the quality of life of bladder cancer survivors. The authors conducted a scoping review of randomized clinical trials (RCTs) to identify knowledge gaps in and research directions for (p)rehabilitative support for those affected by bladder cancer. The authors systematically searched six databases and synthesized key findings from RCTs conducted from January 1, 2004, through March 15, 2022, that enrolled participants with bladder cancer, survivors, or caregivers in outpatient (p)rehabilitative programs (e.g., exercise, nutrition, or psychological support). Outcomes were characterized according to eight prespecified, clinically relevant categories. The search retrieved 10,968 records, 27 of which met the inclusion criteria, and 24 described unique RCTs with 2471 enrolled participants. Of 24 interventions, 17 (71%) yielded statistically significant results for the outcome of interest. Only one RCT included a cost‐effectiveness analysis, and only two characterized the efficacy of interventions for caregivers. Of 11 RCTs involving psychological support, eight yielded statistically significant results, as did nine of 11 RCTs with physical exercise interventions, three of four RCTs with educational interventions, three of four RCTs with nutritional support interventions, one of two RCTs with pharmacologic medications, and zero of one RCT with physical therapy. The most promising interventions for inclusion in multimodal, personalized (p)rehabilitation programs included exercise, stress management training, cognitive training, smoking and alcohol cessation counseling, immunonutrition, stoma education, and penile rehabilitation. Further studies of the cost effectiveness and efficacy for caregivers of such interventions are needed. Plain Language Summary In a scoping review of all randomized clinical trials involving prehabilitative or rehabilitative diet, exercise, and psychological support interventions for patients with bladder cancer, survivors, and their caregivers, 17 of 24 (71%) interventions yielded statistically significant improvements in the outcome of interest. Clinicians should consider implementing such interventions for those affected by bladder cancer.

Background: Carpal Tunnel Syndrome (CTS) is associated with a significant personal and societal burden. Evaluating access to care can identify barriers, limitations, and disparities in the delivery of healthcare services in this population. The purpose of this study was to evaluate access to overall healthcare and healthcare utilization among patients with CTS. Methods: This is a retrospective cohort study conducted with the All of Us database. Patients diagnosed with CTS that completed the access to care survey were included and matched to a control group. The primary outcomes were access to care across 4 domains: (1) delayed care, (2) could not afford care, (3) skipped medications, and (4) over 1 year since seeing provider. Secondary analysis was then performed to identify patient-specific factors associated with reduced access to care. Results: In total, 7649 patients with CTS were included and control matched to 7649 patients without CTS. In the CTS group, 33.7% (n = 2577) had delayed care, 30.4% (n = 2323) could not afford care, 15.4% (n = 1180) skipped medications, and 1.6% (n = 123) had not seen a provider in more than 1 year. Within the CTS cohort, low-income, worse physical health, and worse mental health were associated with poor access to care. Conclusion: Patients experience notable challenges with delayed care, affordability of care, and medication adherence regardless of having a diagnosis of CTS. Targeted interventions on modifiable risk factors such as low income, poor mental health, and poor physical health are important opportunities to improve access to care in this population.

Purpose To evaluate how arthroscopic meniscectomy utilization, reimbursement, physician billing practices, and patient populations have changed within the Medicare population from 2013 to 2021 at a national level and regional level. Methods The Medicare Physician & Other Practitioners database was queried for all episodes of 2‐compartment and single‐compartment arthroscopic meniscectomy between 2013 and 2021. Utilization per 10,000 beneficiaries and average inflation‐adjusted reimbursement were assessed. Physician practice styles, measured through changes in the services billed, and Medicare beneficiary demographic characteristics were extracted each year. The Kruskal‐Wallis test was performed to compare regions. Results Between 2013 and 2021, two‐compartment meniscectomy utilization per 10,000 Medicare beneficiaries declined by 54.9% and single‐compartment meniscectomy utilization declined by 54.2%. Average reimbursement declined by 9.3% and 12.5% for 2‐compartment meniscectomy and single‐compartment meniscectomy, respectively. In 2021, the South had the highest utilization of both 2‐compartment (3.8/10,000) and single‐compartment (4.7/10,000) meniscectomies while having the lowest average reimbursement for 2‐compartment meniscectomy ($383.02, P < .001). Nationally, the average number of beneficiaries per surgeon performing single‐compartment meniscectomy declined by 3.8% whereas the average number of billable services performed per beneficiary increased by 46.6%. The comorbidity risk score of these patients decreased by 8.7%, with the West having the healthiest patients in 2021. Conclusions Meniscectomy utilization and reimbursement have been declining nationally within the Medicare population. Surgeons in the South performed the most meniscectomies while having among the lowest reimbursement. The practice patterns of surgeons performing meniscectomies have been changing, with surgeons performing nearly 50% more total billable services per beneficiary while performing fewer unique billable services. Additionally, the patient population of surgeons who perform meniscectomy was healthier in 2021 than in 2013. Clinical Relevance This study highlights changes in meniscectomy utilization and reimbursement over time in the face of changing evidence of meniscectomy use in elderly patients and new Medicare legislature regarding reimbursement.