The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 8

Scientific Articles | August 01, 2005

The Impact of Infection After Total Hip Arthroplasty on Hospital and Surgeon Resource Utilization

Kevin J. Bozic, MD, MBA¹; Michael D. Ries, MD¹

¹ Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MU 320W, San Francisco, CA 94143-0728. E-mail address for K.J. Bozic: bozick@orthosurg.ucsf.edu

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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Orthopaedic Research and Education Foundation Health Services Research Grant. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Aug 01;87(8):1746-1751. doi: 10.2106/JBJS.D.02937

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Abstract

Background: Deep infection following total hip arthroplasty is a devastating complication for the patient and a costly one for patients, surgeons, hospitals, and payers. The purpose of this study was to compare revision total hip arthroplasty for infection, revision total hip arthroplasty for aseptic loosening, and primary total hip arthroplasty with respect to their impact on hospital and surgeon resource utilization and referral patterns to a tertiary-care hospital.

Methods: Clinical, demographic, and economic data were obtained for twenty-five consecutive patients with an infection after a total hip replacement who underwent a two-stage revision arthroplasty (Group 1) performed by one of two surgeons, between March 2001 and December 2002, at a single institution. Similar data were collected during the same time-period for a cohort of twenty-five consecutive patients who underwent revision of both components because of aseptic loosening (Group 2) and twenty-five consecutive patients who underwent a primary hip arthroplasty (Group 3). Quantitative and categorical variables were compared among the groups. Referral patterns were examined by reviewing the primary diagnosis for all patients referred to our institution for a revision total hip arthroplasty during a five-year period.

Results: Revision procedures for infection were associated with longer operative time, more blood loss, and a higher number of complications compared with revisions for aseptic loosening or primary total hip arthroplasty (p < 0.02 for all). Revisions for infection were also associated with a higher total number of hospitalizations, total number of days in the hospital, total number of operations, total hospital costs, total outpatient visits, and total outpatient charges during the twelve-month period following the index procedure (p < 0.001 for all). The incidence of referrals to our institution for a diagnosis of infection following total hip arthroplasty increased significantly over a five-year period (Spearman rank correlation, 1.0; p = 0.0083), while referral rates for revision for causes other than infection remained relatively constant (Spearman rank correlation, 0.500; p = 0.3910).

Conclusions: The treatment of patients with an infection after a total hip arthroplasty is associated with significantly greater hospital and physician resource utilization compared with the treatment of patients who have a revision because of aseptic loosening or who have a primary total hip arthroplasty. We believe that the lack of incremental reimbursement associated with these procedures results in strong financial disincentives for physicians and hospitals to provide treatment for patients with an infection after a total hip arthroplasty.

Figures in this Article

Deep infection is one of the most devastating complications associated with total hip arthroplasty and occurs in approximately 0.5% to 3% of primary and 4% to 6% of revision total hip arthroplasties^1-3. Infection often results in the need for multiple reoperations, prolonged use of intravenous and oral antibiotics, extended inpatient and outpatient rehabilitation, and frequent follow-up visits. Furthermore, clinical outcomes following single-stage and two-stage revision total joint arthroplasty have been less favorable than those after revision for other causes of failure not associated with infection⁴.

In addition to the clinical impact, infection after a total hip arthroplasty also has substantial economic implications for patients, payers, hospitals, physicians, and society in terms of direct medical costs, resource utilization, and the indirect costs associated with lost wages and productivity. As previous authors have noted⁵, the considerable resources required for hospitals and physicians to provide care for these patients are often poorly reimbursed, resulting in an increased economic burden, particularly on the high-volume tertiary-care referral centers where patients with an infection after an arthroplasty are frequently referred for definitive care.

The specific aims of this study were to quantify and compare resource utilization for patients undergoing primary total hip arthroplasty, revision total hip arthroplasty for aseptic loosening, and revision total hip arthroplasty for infection as well as to evaluate trends in referral patterns for infection after total hip arthroplasty at a tertiary-care referral hospital. The specific hypothesis tested was that hospital and surgeon resource utilization are significantly higher for revision total hip arthroplasty for infection compared with primary total hip arthroplasty or revision total hip arthroplasty for aseptic loosening.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

We used a retrospective cost-identification cohort study design. Clinical and economic data were analyzed for twenty-five consecutive patients with an infection after a total hip arthroplasty who underwent a two-stage revision arthroplasty (Group 1), which was performed by one of two surgeons between March 2001 and December 2002, at a single institution. Similar data were collected for a cohort of twenty-five consecutive patients who underwent revision of both components for a diagnosis of mechanical loosening and/or osteolysis (Group 2) and for a cohort of twenty-five consecutive patients who underwent primary total hip arthroplasty (Group 3) at the same institution during the same time-period. This study was approved by our institution's Committee on Human Research.

Baseline clinical and demographic data analyzed for all groups included age, gender, body mass index, All-Patient Refined Diagnosis-Related Groups Severity of Illness score (APR-DRG SOI), and the presence of segmental, cavitary, or combined femoral and acetabular osseous deficiencies, as defined by the American Academy of Orthopaedic Surgeons classification for femoral and acetabular defects in total hip arthroplasty^6,7. All-Patient DRGs (AP-DRGs) are an expansion of the basic DRGs and are intended to be more descriptive of both Medicare and non-Medicare populations. All-Patient Refined DRGs (APR-DRGs) incorporate severity-of-illness subclasses into AP-DRGs. The APR-DRG Severity of Illness (SOI) is a weighted index that is intended to reflect a patient's baseline medical health and ranges from 1 (lowest severity of illness) to 4 (highest severity of illness)⁸. Measured clinical outcomes included operative time, estimated blood loss, and number of inpatient and outpatient complications related to the index procedure. Recorded complications included deep venous thrombosis and/or pulmonary embolism, myocardial infarction, cardiac arrhythmia, fluid and/or electrolyte imbalance, pneumonia, postoperative hemorrhage, paralytic ileus, dislocation, and nerve palsy. Data on resource utilization included length of hospital stay, discharge disposition, number of hospitalizations, number of surgical procedures, total number of days spent in the hospital, total inpatient hospital costs, number of outpatient visits, and total outpatient charges during the episode of care. The episode of care was defined as the twelve-month period following the index procedure (primary total hip arthroplasty [Group 3], revision total hip arthroplasty for aseptic loosening [Group 2], or resection arthroplasty with implantation of an antibiotic-impregnated cement spacer [Group 1]). All patients in Group 1 underwent a two-stage revision total hip arthroplasty, including a resection arthroplasty with implantation of an antibiotic-impregnated cement spacer, followed by a period of intravenous and/or oral antibiotics (usually four to six weeks, depending on the organism and the recommendation of the infectious disease consultant), and then a subsequent reimplantation procedure within six months after the index procedure. On the basis of the clinical history, the virulence of the organism, serology tests, repeat aspiration, and intraoperative findings, several patients underwent more than one débridement prior to reimplantation. Clinical data were collected from the hospital medical record, the outpatient chart, and our institution's prospective database on clinical outcomes after arthroplasty. Economic data, including actual hospital costs and all charges associated with any outpatient visits during the episode of care, were obtained from the hospital decision support cost-accounting system (TSI, Eclipsys, Brighton, Massachusetts) and the outpatient billing system (IDX Systems, Burlington, Vermont).

Sample Size Determination

Sample size determination was carried out on the basis of the mean values and standard deviations that have been reported for costs associated with primary and revision total joint arthroplasty^9-11. A sample size of approximately twenty-two patients per group was needed to achieve 90% power to detect differences in costs of 25% between groups, assuming a pooled standard deviation of 20% (an effect size of 20/20 = 1.0, Bonferroni a = 0.01, ß = 0.1) with use of the unpaired Student t test. The calculations were performed with nQuery Advisor Software (Statistical Solutions, Boston, Massachusetts). We conservatively set the significance level at 0.05 to minimize the risk of a Type-I (false-positive) error due to multiple intergroup comparisons.

Statistical Methods

Quantitative variables were compared between patient groups with use of the Kruskal-Wallis nonparametric rank test. Categorical variables were compared with use of the Fisher exact test. All analyses were performed with use of SAS software (version 8.2; SAS Institute, Cary, North Carolina) for Microsoft Windows.

Referral Patterns

Referral patterns were examined by reviewing the primary diagnosis for all patients referred to the arthroplasty service at our institution for revision total hip arthroplasty during a five-year period. The number of patients with an infection after total hip arthroplasty as a percentage of the total number of patients referred to our institution for revision total hip arthroplasty per year was also calculated.

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

The differences in baseline clinical and demographic characteristics among the groups are shown in Table I. With the numbers available, no significant differences among the three groups were detected with respect to patient age or body mass index (p > 0.3). There were more men in the group with an infection (Group 1) (p = 0.0090), and both the groups that had revision because of infection or aseptic loosening (Groups 1 and 2) had a higher medical severity of illness score (a measure of baseline comorbid disease) (p < 0.001) and a higher prevalence of substantial femoral and acetabular bone loss (p < 0.001) than the group that had primary total hip arthroplasty (Group 3).

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TABLE I Baseline Clinical and Demographic Characteristics of Patients Who Underwent Primary Total Hip Arthroplasty, Revision Total Hip Arthroplasty for Aseptic Loosening, and Revision Total Hip Arthroplasty for Infection

	Group 1 (Revision Arthroplasty for Infection) (N = 29)	Group 2 (Revision Arthroplasty for Aseptic Loosening) (N = 27)	Group 3 (Primary Arthroplasty) (N = 29)	P Value
				Overall	Comparison of Groups 1 and 2	Comparison of Groups 1 and 3	Comparison of Groups 2 and 3
Age^* (yr)	56.7 ± 15.109	61.9 ± 15.5	57.5 ± 15.0	0.33	0.15	0.63	0.32
Gender
Women	7	16	17	0.009	0.014	0.016	1.00
Men	22	11	12
Body mass index^*	27.2 ± 6.2	27.7 ± 6.7	27.7 ± 5.5	0.99	0.96	0.94	0.82
APR-DRG SOI score† (no. of hips)
1	2	2	13
2	16	16	13
3	9	9	3
4	2	0	0	<0.001	0.80	<0.001	<0.001
Acetabular deficiency (no. of hips)	26	20	3	<0.001	0.17	<0.001	<0.001
Femoral deficiency (no. of hips)	28	25	6	<0.001	1.00	<0.001	<0.001

^*The values are given as the mean and the standard deviation. †APR-DRG SOI = All Patient-Refined Diagnosis-Related Group Severity of Illness.

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	Group 1 (Revision Arthroplasty for Infection) (N = 29)	Group 2 (Revision Arthroplasty for Aseptic Loosening) (N = 27)	Group 3 (Primary Arthroplasty) (N = 29)	P Value
				Overall	Comparison of Groups 1 and 2	Comparison of Groups 1 and 3	Comparison of Groups 2 and 3
Age^* (yr)	56.7 ± 15.109	61.9 ± 15.5	57.5 ± 15.0	0.33	0.15	0.63	0.32
Gender
Women	7	16	17	0.009	0.014	0.016	1.00
Men	22	11	12
Body mass index^*	27.2 ± 6.2	27.7 ± 6.7	27.7 ± 5.5	0.99	0.96	0.94	0.82
APR-DRG SOI score† (no. of hips)
1	2	2	13
2	16	16	13
3	9	9	3
4	2	0	0	<0.001	0.80	<0.001	<0.001
Acetabular deficiency (no. of hips)	26	20	3	<0.001	0.17	<0.001	<0.001
Femoral deficiency (no. of hips)	28	25	6	<0.001	1.00	<0.001	<0.001

^*The values are given as the mean and the standard deviation. †APR-DRG SOI = All Patient-Refined Diagnosis-Related Group Severity of Illness.

Clinical outcomes are shown in Table II. Significant differences were found between the two revision groups (Groups 1 and 2) and the primary group (Group 3) with respect to operative time and estimated blood loss (p < 0.001). Estimated blood loss and the total number of complications were also significantly higher in the group with an infection (Group 1) than in the group that had revision because of aseptic loosening (Group 2) (p < 0.02 for both). Although Group 2 had a higher prevalence of complications than the primary total hip arthroplasty group (Group 3), with the numbers available, the difference did not reach significance (p = 0.36).

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TABLE II Clinical Outcomes Following Primary Total Hip Arthroplasty, Revision Total Hip Arthroplasty for Aseptic Loosening, and Revision Total Hip Arthroplasty for Infection

	Group 1 (Revision Arthroplasty for Infection) (N = 29)	Group 2 (Revision Arthroplasty for Aseptic Loosening) (N = 27)	Group 3 (Primary Arthroplasty) (N = 29)	P Value
				Overall	Comparison of Groups 1 and 2	Comparison of Groups 1 and 3	Comparison of Groups 2 and 3
Operating-room time^* (min)	277.8 ± 73.3	298.9 ± 78.6	177.3 ± 44.3	<0.001	0.27	<0.001	<0.001
Estimated blood loss^* (mL)	2082 ± 1547	1569 ± 1318	449 ± 99	<0.001	0.015	<0.001	<0.001
Total no. of complications per patient^*	1.9 ± 2.2	0.7 ± 1.0	0.5 ± 0.7	0.004	0.019	0.002	0.36

The values are given as the mean and the standard deviation.

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TABLE II Clinical Outcomes Following Primary Total Hip Arthroplasty, Revision Total Hip Arthroplasty for Aseptic Loosening, and Revision Total Hip Arthroplasty for Infection

	Group 1 (Revision Arthroplasty for Infection) (N = 29)	Group 2 (Revision Arthroplasty for Aseptic Loosening) (N = 27)	Group 3 (Primary Arthroplasty) (N = 29)	P Value
				Overall	Comparison of Groups 1 and 2	Comparison of Groups 1 and 3	Comparison of Groups 2 and 3
Operating-room time^* (min)	277.8 ± 73.3	298.9 ± 78.6	177.3 ± 44.3	<0.001	0.27	<0.001	<0.001
Estimated blood loss^* (mL)	2082 ± 1547	1569 ± 1318	449 ± 99	<0.001	0.015	<0.001	<0.001
Total no. of complications per patient^*	1.9 ± 2.2	0.7 ± 1.0	0.5 ± 0.7	0.004	0.019	0.002	0.36

The values are given as the mean and the standard deviation.

Differences in hospital and physician resource utilization per patient are shown in Table III. The hospital costs associated with revision total hip arthroplasties (Groups 1 and 2) were significantly greater than those associated with primary arthroplasty (Group 3) (p < 0.001). There were significant differences among the three groups with respect to the total number of hospitalizations, total number of days in the hospital, total number of operations, total hospital costs, total outpatient visits, and total outpatient charges during the episode of care. For each of these variables, resource utilization was significantly greater for Group 1 compared with Groups 2 and 3 (p < 0.001 in all cases).

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TABLE III Resource Utilization Per Patient During the Episode of Care for Primary Total Hip Arthroplasty, Revision Total Hip Arthroplasty for Aseptic Loosening, and Revision Total Hip Arthroplasty for Infection^*

				P Value
	Group 1 (Revision Arthroplasty for Infection)† (N = 29)	Group 2 (Revision Arthroplasty for Aseptic Loosening)† (N = 27)	Group 3 (Primary Arthroplasty)† (N = 29)	Overall	Comparison of Groups 1 and 2	Comparison of Groups 1 and 3	Comparison of Groups 2 and 3
No. of hospitalizations	3.6 ± 2.1	1.2 ± 0.5	1.2 ± 0.4	<0.001	<0.001	<0.001	0.85
Total no. of days in hospital	28.2 ± 20.9	8.1 ± 5.3	6.2 ± 2.4	<0.001	<0.001	<0.001	0.38
Total no. of operations	3.690 ± 2.222	1.407 ± 0.888	1.0 ± 0.2	<0.001	<0.001	<0.001	0.032
Total hospital costs (US$)	96,166 ± 60,664	34,866 ± 15,547	21,654 ± 4291	<0.001	<0.001	<0.001	<0.001
No. of outpatient visits	54.6 ± 35.1	28.2 ± 27.6	17.2 ± 11.8	<0.001	<0.001	<0.001	0.16
Total outpatient charges (US$)	48,348 ± 27,965	16,411 ± 9478	8519 ± 4185	<0.001	<0.001	<0.001	<0.001

^*An episode of care is defined as a twelve-month period following the index procedure. †The values are given as the mean and the standard deviation.

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				P Value
	Group 1 (Revision Arthroplasty for Infection)† (N = 29)	Group 2 (Revision Arthroplasty for Aseptic Loosening)† (N = 27)	Group 3 (Primary Arthroplasty)† (N = 29)	Overall	Comparison of Groups 1 and 2	Comparison of Groups 1 and 3	Comparison of Groups 2 and 3
No. of hospitalizations	3.6 ± 2.1	1.2 ± 0.5	1.2 ± 0.4	<0.001	<0.001	<0.001	0.85
Total no. of days in hospital	28.2 ± 20.9	8.1 ± 5.3	6.2 ± 2.4	<0.001	<0.001	<0.001	0.38
Total no. of operations	3.690 ± 2.222	1.407 ± 0.888	1.0 ± 0.2	<0.001	<0.001	<0.001	0.032
Total hospital costs (US$)	96,166 ± 60,664	34,866 ± 15,547	21,654 ± 4291	<0.001	<0.001	<0.001	<0.001
No. of outpatient visits	54.6 ± 35.1	28.2 ± 27.6	17.2 ± 11.8	<0.001	<0.001	<0.001	0.16
Total outpatient charges (US$)	48,348 ± 27,965	16,411 ± 9478	8519 ± 4185	<0.001	<0.001	<0.001	<0.001

^*An episode of care is defined as a twelve-month period following the index procedure. †The values are given as the mean and the standard deviation.

Referral Patterns

Trends in referral patterns to our tertiary-care hospital for patients requiring revision total hip arthroplasty are shown in Table IV. As a percentage of all patients referred to us for revision total hip arthroplasty, the percentage of patients referred for a diagnosis of infection after total hip arthroplasty increased steadily from 5% (three of fifty-nine) in 1999 to 17% (fifteen of eighty-seven) in 2003. Although the number of patients who were referred for revision total hip arthroplasty for causes other than infection did not increase significantly during this time-period (Spearman rank correlation, 0.500; p = 0.3910), the number of patients referred for revision total hip arthroplasty because of an infection increased fourfold during the same time-period (Spearman rank correlation, 1.00; p = 0.0083).

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TABLE IV Number of Patients Referred to Our Tertiary-Care Medical Center Between 1999 and 2003 for Revision Total Hip Arthroplasty for Aseptic Causes and Revision Total Hip Arthroplasty for Infection

Year	All Revision Total Hip Arthroplasties	Revision Arthroplasty for Aseptic Causes	Revision Arthroplasty for Infection	Percentage of Revision Arthroplasties for Infection
1999	59	56	3	5
2000	81	74	7	9
2001	79	70	9	11
2002	91	79	12	13
2003	87	72	15	17
Spearman rank correlation^*	0.800 (-0.28 to 09.986)	0.500 (-0.684 to 0.959)	1.000 (0.936 to 1.000)
Spearman p value	0.1041	0.391	0.0083†

^*The 95% confidence interval is given in parentheses. †By permutation test.

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TABLE IV Number of Patients Referred to Our Tertiary-Care Medical Center Between 1999 and 2003 for Revision Total Hip Arthroplasty for Aseptic Causes and Revision Total Hip Arthroplasty for Infection

Year	All Revision Total Hip Arthroplasties	Revision Arthroplasty for Aseptic Causes	Revision Arthroplasty for Infection	Percentage of Revision Arthroplasties for Infection
1999	59	56	3	5
2000	81	74	7	9
2001	79	70	9	11
2002	91	79	12	13
2003	87	72	15	17
Spearman rank correlation^*	0.800 (-0.28 to 09.986)	0.500 (-0.684 to 0.959)	1.000 (0.936 to 1.000)
Spearman p value	0.1041	0.391	0.0083†

^*The 95% confidence interval is given in parentheses. †By permutation test.

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

Our findings indicate that the total direct medical costs associated with revision total hip arthroplasty because of an infection are 2.8 times higher than the direct medical costs associated with revision total hip arthroplasty because of aseptic loosening and 4.8 times higher than the direct medical costs associated with primary total hip arthroplasty. Furthermore, revision of a total hip arthroplasty because of infection was associated with significantly more hospitalizations, total days in the hospital, number of operations, outpatient visits, outpatient charges, and complications than was revision because of aseptic loosening or primary total hip arthroplasty.

The estimated prevalence of infection following total hip arthroplasty has been reported to range from 0.5% to 7.5%^12-14. Risk factors for infection are influenced by many variables that include patient, procedure, surgeon, and hospital characteristics. Patient factors that have been associated with a higher risk of infection following total hip arthroplasty include rheumatoid arthritis, diabetes mellitus, poor nutrition, obesity, sickle-cell disease, previous solid organ transplant, use of oral steroids, immune system compromise, and a history of surgery on the affected joint^1,2. Procedure and surgeon-related factors that contribute to the risk of infection include the timing and dosage of perioperative antibiotics, operative time, surgical technique and/or handling of the soft tissues, operating-room traffic, and the complexity of the reconstruction^1,12,15. Several studies have recently shown that infection rates following total joint arthroplasty are inversely proportional to hospital and surgeon volume^16-18.

Several other investigators have attempted to quantify the economic impact of infection after total joint arthroplasty^5,19. Sculco⁵ estimated the economic impact of infection after total joint replacements at The Hospital for Special Surgery in New York. On the basis of Medicare data from 1986 to 1989, he estimated the prevalence of infection after total joint arthroplasty in the United States to be approximately 3500 to 4000 cases per year, at an average cost of $50,000 to $60,000 per case, and an overall annual cost of $150 million to $200 million. Noting the disproportionate burden of care that is assumed by high-volume joint replacement centers that often provide care for these patients, he recommended that a method for case sharing be established by medical centers that are best equipped to care for these patients. Furthermore, he suggested that reimbursement to both hospitals and physicians should more realistically reflect the magnitude of resources consumed by these patients.

Hebert et al.¹⁹ compared direct medical costs among patients who had primary total knee arthroplasty, revision total knee arthroplasty because of aseptic loosening, and revision total knee arthroplasty because of infection. They reported that the surgical treatment of patients with an infection after total knee arthroplasty required three to four times the amount of resources of the hospital and the surgeon compared with those required for a primary procedure and approximately twice those required for revision total knee arthroplasty because of aseptic loosening. Furthermore, they found that the insufficient reimbursement resulted in an estimated net loss to the hospital of approximately $15,000 per patient and $30,000 per Medicare patient.

Our study builds on the findings of previous investigators by using a larger sample size, longer duration of follow-up, and more complete information regarding resource utilization during the entire twelve-month episode of care. Furthermore, unlike previous studies^5,19,20 that have used billed charges or cost-to-charge ratios to compare resource utilization between different types of procedures, our study used actual hospital costs obtained from our hospital decision support system. We consider this to be a primary strength of our study, since many health economists have noted that charges are an inaccurate measure of health-care resource utilization for many reasons, most importantly the fact that the economic basis of charges differs substantially among health-care facilities and geographic locations^21,22.

Limitations

Our study has several limitations. Our analysis focuses only on direct medical costs and does not consider nonmedical or indirect costs to the patient and to society associated with lost wages and productivity. Given the prolonged period of convalescence usually associated with the treatment of an infection after a total hip arthroplasty, it is likely that the inclusion of these other costs would only strengthen the conclusion that our treatment is associated with greater resource utilization than is revision total hip arthroplasty because of aseptic loosening or primary total hip arthroplasty. Additionally, our analysis is limited to the experience of two surgeons from a single institution in a single geographic location. The benefit of using data from a single institution is the ability to obtain detailed, patient-specific cost and clinical data, including the cause of the revision, femoral and acetabular bone loss, operative time, estimated blood loss, and length of stay. However, limiting the analysis to data from a single institution tempers the generalizability of the results. Further study is necessary in order to determine whether our experience is similar to that of other tertiary-care referral centers. Finally, although our findings demonstrated a significant increase in the number of patients referred to our institution for revision total hip arthroplasty because of infection, we do not know the rate of referrals for revision total hip arthroplasty because of infection to other (nontertiary-care) institutions in our area. Unfortunately, because of issues related to confidentiality, we do not have access to specific information regarding infection rates after total hip arthroplasty from our referring institutions. However, our institution receives referrals from a wide catchment area and, although the number of referrals of total hip replacements that have failed due to causes other than infection has remained relatively constant during the time-period of this study, the percentage of patients referred for revision total hip arthroplasty because of infection has increased fourfold during the same time-period. This could indicate either that there has been a substantial increase in the prevalence of patients with an infection after a total hip arthroplasty in our region or that there has been an increase in the percentage of patients with an infection after a total hip arthroplasty who have been referred to our institution. Since neither the publicly reported data on hospital infection rates in our area nor the data in the orthopaedic literature¹ have shown a similar increase in the prevalence of deep infection after total hip arthroplasty, our assumption is that the latter scenario is more likely to be the case.

In conclusion, the additional time and resource utilization required to provide care for patients with an infection after a total joint arthroplasty, coupled with the lack of incremental reimbursement, has resulted in a substantial economic burden assumed by surgeons and hospitals that provide care for these patients. Consequently, we believe there is an economic disincentive for hospitals and surgeons to accept patients with an infection after a total joint arthroplasty that has been reflected by a consistent increase in referrals of such patients to our tertiary-care institution over the past five years.

Several investigators have demonstrated a direct association between hospital and surgeon procedure volume and better clinical outcomes in terms of readmissions, reoperations, complications, and mortality rates^16-18. If this observation is also true for the care of patients with an infection after a total hip arthroplasty, the economic burden that results from the disproportionate resource utilization and a concomitant lack of incremental reimbursement will further contribute to the financial problems that currently plague many tertiary-care referral centers²³. As a result of the strong financial disincentives that have been created under current reimbursement patterns, certain high-volume joint replacement centers have already considered restricting access for patients with an infection after a total joint arthroplasty⁵. If these trends continue, they could have a detrimental impact on access to care and clinical outcomes for patients who experience this debilitating complication.

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

Note: The authors acknowledge the contributions of Harry E. Jergesen, MD, and Alan Bostrum to this study.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

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Topics

patient referral ; infection ; arthroplasty ; hip replacement arthroplasty

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Kevin J. Bozic, Michael D. Ries; The Impact of Infection After Total Hip Arthroplasty on Hospital and Surgeon Resource Utilization. The Journal of Bone & Joint Surgery. 2005 Aug;87(8):1746-1751.

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