ORIGINAL ARTICLE

Adverse Events in Orthopaedics: Is Trauma More Risky? An Analysis of the NSQIP Data Vasanth Sathiyakumar, BA, Rachel V. Thakore, BS, Sarah E. Greenberg, BA, Paul S. Whiting, MD, Cesar S. Molina, MD, William T. Obremskey, MD, MPH, MMHC, and Manish K. Sethi, MD

Objectives: As our healthcare system moves toward bundling payments, orthopaedic trauma surgeons will be increasingly benchmarked on perioperative complications. We therefore sought to determine financial risks under bundled payments by identifying adverse event rates for (1) orthopaedic trauma patients compared with general orthopaedic patients and (2) based on anatomic region and (3) to identify patient factors associated with complications.

Design: Prospective. Setting: Multicenter. Patients/Participants: A total of 146,773 orthopaedic patients (22,361 trauma) from 2005 to 2011 NSQIP data were identified.

Interventions: Minor and major adverse events, demographics, surgical variables, and patient comorbidities were collected. Main Outcome Measurements: Multivariate regressions determined significant risk factors for the development of complications. Results: The complication rate in the trauma group was 11.4% (2554/22,361) versus 4.1% (5137/124,412) in the general orthopaedic group (P = 0.001). When controlling for all variables, trauma was a risk factor for developing complications [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.57–1.81]. After controlling for several patient factors, hip and pelvis patients were 4 times more likely to develop any perioperative complication than upper extremity patients (OR: 3.79, 95% CI: 3.01–4.79, P = 0.01). Lower extremity patients are 3 times more likely to develop any complication versus upper extremity patients (OR: 2.82, 95% CI: 2.30–3.46, P = 0.01).

Conclusions: Our study is the first to show that orthopaedic trauma patients are 2 times more likely than general orthopaedic patients to sustain complications, despite controlling for identical risk factors. Accepted for publication January 13, 2015. From the The Vanderbilt Orthopaedic Institute Center for Health Policy, Nashville, TN. Presented in part at the Annual Meeting of the OTA, October 18, 2014, Tampa, FL. W. T. Obremskey has done expert testimony in legal matters. The institution of one or more authors (W.T.O.) has received a grant from the Department of Defense. The remaining authors report no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www.jorthotrauma.com). Reprints: Manish K. Sethi, MD, The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

J Orthop Trauma  Volume 29, Number 7, July 2015

There is also an alarming difference in complication rates among anatomic regions. Orthopaedic trauma surgeons will face increased financial risk with bundled payments. Key Words: adverse events, trauma, NSQIP

Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. (J Orthop Trauma 2015;29:337–341)

INTRODUCTION National healthcare costs continue to rise and comprised 17.2% of the US GDP in 2012.1 As a result of increasing health care expenditure, we are moving toward a bundled payment system in which physicians are increasingly benchmarked on perioperative adverse events to reduce complication rates.2 In fact, Medicare is currently bundling payments for selected areas like major joint arthroplasty, with the intention of expanding this system across all of orthopaedics based on the results of this select pilot program.3–5 Under this system, treatment costs for complications and readmissions would be covered under index lump sum payments without additional reimbursement.6,7 The success of a bundled care system in orthopaedics, therefore, depends on maintaining low complication rates. However, individual studies in orthopaedic trauma have demonstrated high rates of adverse events. Orthopaedic traumatologists consequently may face the greatest financial losses in a bundled payment system compared with other orthopaedists.8 Although many insurers group trauma as a subspecialty within orthopaedics for benchmarking adverse events, it is important to evaluate if differences exist, especially in the current payer environment. Even within orthopaedic trauma, there is considerable variation in adverse events based on anatomic location: Hip fractures have complication rates ranging from 3% to 57% of all patients, tibia adverse events range from 5% to 37% of all patients, and complications secondary to humerus fractures include 2% to 35% of all patients.9–17 Because 11% of orthopaedists are specialized in trauma and close to 70% of orthopaedists take trauma call at affiliated hospitals in the United States, the financial risks with bundling payments for orthopaedic trauma patients are an important issue affecting the majority of US orthopaedists.18 As a means to mitigate reimbursement losses, 1 method is to reduce complications by identifying high-risk patients who may develop adverse events through easily collectable www.jorthotrauma.com |

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Sathiyakumar et al

and measurable risk factors. The identification of these patient factors allows for the development of risk calculators and would provide orthopaedic traumatologists a mechanism to risk stratify which patients are the most likely to develop adverse events. Reducing overall complication rates in these high-risk patients may therefore provide financial stability under a bundled payment system. We have 3 main purposes in this article. The first is to identify the rates of adverse events in orthopaedic trauma patients compared with patients in general orthopaedics through the use of prospective multicenter data in the American College of Surgeons’ National Surgical Quality Improvement Program database. By comparing these complication rates, we determine whether orthopaedic traumatologists face greater financial risks in a bundled care system. Our second purpose is to identify whether specific anatomic regions within orthopaedic trauma result in greater financial risks to further risk-stratify patients. Finally, our third goal is to identify patient risk factors that significantly predispose high-risk patients toward the development of perioperative adverse events. Through these 3 goals, we hope to provide results that will be used to develop risk calculators for orthopaedic trauma patients. Early risk stratifying of patients will help orthopaedic traumatologists adapt to a bundled care reimbursement system by maintaining overall low complication rates.

hypertension requiring medication, peripheral vascular disease, esophageal varices, disseminated cancer, bleeding disorders, steroid use, dialysis, chemotherapy, radiotherapy, and dyspnea. Separate multivariable regressions for minor, major, and any adverse events based on orthopaedic procedure (trauma vs. other) were run controlling for the same covariates to compare and contrast which significant risk factors contributed to the development of these adverse events between orthopaedic trauma and other orthopaedic subspecialties. The orthopaedic trauma patients were then divided into 3 anatomic regions: upper extremity (UE), hip/pelvis (HP), and lower extremity (LE) based on fracture location. Demographics for patients based on anatomic region were recorded and compared using Fisher exact tests. Rates of adverse events (major, minor, and any) were tallied and compared among the 3 groups using x2 tests. Separate multivariable regressions controlling for similar covariates as before (ie, age, medical comorbidities, ASA status, operative time, and baseline functional status) were run for each of the 3 anatomic regions to note significant patient risk factors that predicted the development of minor, major, or any adverse events.

RESULTS

After institutional IRB approval, all patients undergoing orthopaedic procedures from 2005 to 2011 were identified in the NSQIP database through a Current Procedural Terminology (CPT) code search (n = 1066 CPTs). Among these patients, a second CPT code search using only orthopaedic trauma CPT codes (n = 91 CPTs) was conducted to find all patients undergoing orthopaedic trauma procedures. Patients therefore were divided into “trauma” or “other” depending on what type of orthopaedic procedure they had. Basic demographic information for each group was collected and compared using Fisher exact tests, including age, gender, and body mass index (BMI). Percentages of adverse events for both groups were tallied and compared using Fisher exact tests. Adverse events were divided into minor adverse events and major adverse events based on previous NSQIP literature.19,20 Minor adverse events included pneumonia, urinary tract infection, superficial wound infection, and wound dehiscence. Major adverse events included death, deep wound infection, organ/space infection, deep vein thrombosis, stroke, pulmonary embolism myocardial infarction, coma, peripheral nerve injury, sepsis, and septic shock. All patients with complete data were combined in a multivariate analysis controlling for age, The American Society of Anesthesiologists (ASA) physical status, operative time, anesthesia type, and baseline functional status to determine whether an orthopaedic trauma procedure was significantly associated with the development of any adverse event. Medical comorbidities included alcohol abuse, active smoking, and a history of the following: 10% weight loss in the 6 months before surgery, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF),

A total of 146,773 patients who underwent orthopaedic procedures were identified from 2005 to 2011 in the NSQIP database. Of these patients, 22,361 underwent orthopaedic trauma procedures (trauma) and 124,412 patients had procedures categorized under other orthopaedic subspecialties (other). Basic demographics comparing these 2 groups are provided in Table 1. There were significant differences (P , 0.01) between the groups with respect to all demographic measures: Orthopaedic trauma patients were overall younger, had a greater percentage of female patients, had more patients with diabetes and functional dependence status, and were generally less overweight compared with their counterparts. However, they were overall sicker at the time of surgery with a greater percentage of patients categorized with ASA scores greater than 2. Figure 1 compares the minor, major, and total adverse event rates between the 2 groups. There were significant differences (P , 0.01) in the rates of adverse events, with orthopaedic trauma patients having higher rates of minor (6.2% vs. 2.2%), major (7.1% vs. 2.4%), and total perioperative complication rates (11.4% vs. 4.1%) compared with their counterparts. Supplemental Digital Content 1 (http://links.lww. com/BOT/A402) lists the significant risk factors as a result of multivariate analysis controlling for age, gender, ASA score, patient comorbidities, and operative factors to note whether any risk factor—especially the presence of an orthopaedic trauma procedure—significantly predicted the development of adverse events. The presence of an orthopaedic trauma procedure was significantly associated with 1.69 times greater odds (95% confidence interval: 1.57–18.1, P , 0.01) of developing a complication compared with nonorthopaedic trauma surgeries. Other significant risk factors when combining all patients together included demographics such as age and gender, patient comorbidities including history of

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METHODS

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Adverse Events Trauma

TABLE 1. Demographics and Results Overview of Trauma Versus Other Orthopaedics

Selected demographics, n (%) Age, y .65 ,65 Gender Male Female Diabetes Dependent BMI .35 ,35 ASA score .2 ,2 Complications, n (%) All Major Minor

Risk factors for complications, OR (95% CI) All complications Esophageal varices Minor complications Anesthesia type Major complications Male gender

Other Ortho (n = 124,412)

Ortho Trauma (n = 22,361)

43,997 (35.4) 80,415 (64.6)

12,505 (55.9) 20,836 (44.1)

,0.01

59,359 65,053 16,619 5070

8150 14,211 3673 6101

(36.5) (63.5) (16.4) (27.5)

,0.01 ,0.01 ,0.01

27,247 (22.2) 97,165 (77.8)

2428 (11.8) 19,933 (88.2)

,0.01

45,464 (36.6) 78,948 (63.4)

12,722 (57.0) 9639 (43.0)

,0.01 ,0.01

2554 (11.4) 1592 (7.1) 1384 (6.2)

,0.05 ,0.05 ,0.05

Other Ortho

Ortho Trauma

P

1.56 (0.51–4.72)

3.51 (1.33–9.25)

0.01

0.99 (0.96–1.01)

1.05 (1.01–1.10)

0.01

1.09 (1.00–1.19)

1.32 (1.15–1.50)

0.01

(47.9) (52.1) (13.4) (4.1)

5137 (4.1) 2973 (2.4) 2733 (2.2)

P

CI, confidence interval; OR, odds ratio.

COPD, CHF, and cancer among others, and operative factors including length of surgery (Supplemental Digital Content 1, http://links.lww.com/BOT/A402). Supplemental Digital Content 2 (http://links.lww. com/BOT/A403) provides direct comparisons of significant risk factors for the development of minor, major, or any adverse events between orthopaedic trauma and other orthopaedic specialties after multivariable analyses. For minor adverse events, anesthesia type (ie, general vs. regional) was uniquely significant for orthopaedic trauma; male gender was the only factor associated with increased odds of major events for orthopaedic trauma patients not seen in patients of other specialties; and the presence of esophageal varices predicted any adverse event for orthopaedic trauma patients but not for patients of other specialties (see Table 1). Demographics comparing patients within orthopaedic trauma based on anatomic region (UE, HP, LE) are provided in Supplemental Digital Content 3 (http://links. lww.com/BOT/A404). There were significant differences Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

(P , 0.01) among the anatomic regions with respect to all demographic measures: HP patients had the greatest proportion patients over 65 years old, had the greatest percentage of female patients, and were more likely to have a BMI ,35, whereas LE patients were more likely to have diabetes and functional dependent status compared with the other groups. Supplemental Digital Content 4 (http://links.lww. com/BOT/A401) compares the minor, major, and total adverse event rates in orthopaedic trauma patients based on anatomic region. There were significant differences (P , 0.01) in the rates of all types of adverse events, with HP patients having the greatest percentage of minor (10.7%), major (11.6%), and total perioperative complication rates (19.0%) based on the total number of patients, and UE patients having the lowest percentage of minor (1.3%), major (2.0%), and total (3.0%) complication rates. LE patients were intermediate, with 7.5% of patients sustaining a minor complication, 9.1% of patients having a major complication, and 14.2% of patients have any adverse event. Supplemental Digital Content 5 (http://links.lww. com/BOT/A405) provides the significant results from multivariable analysis predicting the development of a minor, major, or any adverse event based on anatomic region. For UE patients, operative time greater than 90 minutes and preoperative functional status predicted all types of adverse events, and ASA scores greater than 2 predicted any major adverse event and total adverse events. For HP patients, ASA scores greater than 2 correlated with all types of adverse events, whereas weight loss, dyspnea, and the history of CHF predicted all major complications and total complications. Age greater than 65 years, ASA score greater than 2, presence of dyspnea, operative time greater than 90 minutes, and preoperative functional status were significantly associated with the development of minor, major, and total adverse events in LE patients.

DISCUSSION

Our study is the first to show through multicenter prospective data that orthopaedic trauma procedures are associated with higher adverse event rates compared with general orthopaedic procedures. The presence of an orthopaedic trauma procedure was independently predictive of greater complication risks despite similar demographic, patient comorbidities, and surgical risk factors. Furthermore, within orthopaedic trauma, there are significant differences in complication rates based on anatomic region with HP patients having the greatest risk of all types of adverse events compared with UE patients who had the lowest risk of developing adverse events. Through multivariate analysis, we demonstrated that various demographic factors, patient comorbidities, and surgical factors significantly increased the odds of developing adverse events for orthopaedic trauma patients as a whole and based on anatomic region. Our first purpose was to determine whether orthopaedic traumatologists would face increased financial risks under a bundled care system. Because of higher incidences of minor and major adverse events, our results suggest that orthopaedic trauma surgeons would have greater financial losses compared with other orthopaedists. By treating a higher rate of www.jorthotrauma.com |

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FIGURE 1. Complication rates for trauma versus other. Editor’s note: A color image accompanies the online version of this article.

complications that may not be reimbursed through bundled payments, orthopaedic traumatologists should not be benchmarked within general orthopaedics. Bundled payments have been implemented by Medicare through pilot programs in specialties and procedures typically associated with high costs and rates of adverse outcomes.21 Specifically for orthopaedic trauma, hip and LE fractures account for 2 of the top 17 most expensive conditions reimbursed by Medicare. As a result of these increased costs, Medicare has targeted these 2 areas in addition to fractures of the humerus for pilot bundled care programs.22,23 Out of the total lump sum payments provided to hospitals for the treatment of patients presenting with one of the top 17 most expensive conditions, readmission costs accounted for only 23% of index bundled payments.24 The majority of payments covered costs associated with the index hospitalization. Given the high rates of adverse events in orthopaedic trauma patients, hospitals and orthopaedic traumatologists would undoubtedly face challenges in covering the costs of readmission and providing quality care using only one-fourth of index payments to cover hospital services, physician services, ancillary care services, imaging, medications, etc., during the rehospitalization. Furthermore, given that trauma patients with extremity injuries require high rates of inpatient services such as ancillary care, predicting how lump sum payments will be distributed among various factors such as index hospitalization services, discharge care, and readmission care is more difficult to predict.21,25 Therefore, although financial risks are already inherent within orthopaedic trauma surgery, future losses may only be compounded with bundled care if complication rates are not decreased. Our second main purpose was to determine whether any specific areas within orthopaedic trauma based on anatomic region increased financial risk under a bundled care system. Within orthopaedic trauma, our study found that hip and pelvis fractures were associated with the greatest percentage of adverse events compared with UE or LE fractures. It therefore follows that traumatologists focusing on these surgeries disproportionately face greater financial risks compared with orthopaedic trauma surgeons who do not treat large numbers of hip and pelvic fractures. According to an article by Birkmeyer et al24 investigating costs attributable to

hip fracture surgery under a bundled care model, postacute care covering complications only accounted for 27% ($7585) of the total bundled payments, with 16% of index payments ($4454) covering readmission costs. The majority of costs were again spent on index hospitalization fees and services, with less than one-fifth of all payments available to cover fees and services associated with any readmission.24 The disproportionately low percentage of costs available to cover complications and readmissions highlights the importance of risk stratifying patients even within orthopaedic trauma. Additional studies are necessary to fully elucidate which fracture locations within each anatomic region predispose patients toward having the highest adverse event rates. Our third main purpose was to determine significant patient risk factors that correlated with the development of adverse events. Having a mechanism to determine which patients will develop adverse events is an invaluable tool for risk stratification. Our study provides initial groundwork in developing risk calculators for orthopaedic trauma patients by identifying multiple significant risk factors that predict the occurrence of minor and major adverse events. All risk factors used in this study are easily collectable metrics that may be measured under any hospital setting and are part of routine perioperative patient workup. Identifying these high-risk patients postoperatively may result in changed management including more frequent bedside checks by nurses and orthopaedists, serial laboratories to rule out infections in predisposed patients, and possibly involving multidisciplinary care for more morbid events such as stroke and sepsis. For orthopaedic trauma patients as a whole, our risk factors were similar to those found in other studies investigating complication rates with orthopaedic injuries. For example, in a 2013 study by Pugely et al,26 significant risk factors for the development of any adverse event after elective primary total knee included male gender, older age, history of cancer, presence of bleeding disorders, and higher ASA class. Similar risk factors were found for total hip replacement patients, with higher BMI, steroid use, history of bleeding disorder, and dependent functional status significantly predicting complications.26 In our study, all of these risk factors were predictive for any adverse event in orthopaedic trauma

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patients. We further found correlations among our anatomic analysis and results in the literature. For example, Martin et al27 used NSQIP data to find significant 30-day morbidity and mortality risk factors after shoulder arthroscopy, including history of smoking, COPD, operative time .90 minutes, and higher ASA scores. In our study, although we focused on trauma patients with traumatic UE injuries instead, we nevertheless found increased ASA score and operation time as predictive for the development of a complication. Our study therefore has some external validation from the literature in the use of these patient variables as part of risk calculators to predict complication rates in high risk. Our study had some limitations. For one, we were limited by the available variables in the NSQIP data set. Therefore, other factors that may have caused adverse events such as social factors were not available for analysis. Furthermore, the adverse event available for analysis was predefined by NSQIP and not specific for orthopaedic patients. Complications unique to orthopaedics, such as nonunions, malunions, hardware pain, or prominence, therefore were not evaluated, and our adverse event rates may actually underrepresent the true complication rates reported in this article. Cost data are not provided in the NSQIP database, which would have aided in comparing direct costs between orthopaedic traumatologists and other orthopaedists as well as within orthopaedic trauma. Nevertheless, our study provides evidence that orthopaedic traumatologists would face greater financial risks under a bundled care system—especially those who treat a majority of hip and pelvic fractures—because of high rates of adverse events. To remain financially stable, complications may decrease through the development and use of novel risk calculators based on our risk factors to risk-stratify patients by identifying those patients who are most likely to develop complications. Future studies are necessary to determine the validity of these risk factors to see if they actually decrease complication rates, and further cost analysis is necessary especially in the field of orthopaedic trauma. Identifying which specific procedures among these anatomic areas will be a necessary next step in further risk-stratifying patients.

Adverse Events Trauma

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

REFERENCES 1. National health expenditures 2012 highlights. Centers for medicare & Medicaid services. Available at: http://www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/ NationalHealthAccountsHistorical.html. Accessed May 16, 2014. 2. Bundled payment: AHA research synthesis report. American hospital association committee on research. 2010. Available at: http://www.aha. org/research/cor/content/BundledPayment.pdf. Accessed May 16, 2014. 3. Sood N, Huckfeldt PJ, Escarce JJ, et al. Medicare’s bundled payment pilot for acute and postacute care: analysis and recommendations on where to begin. Health Aff. 2011;30:1708–1717. 4. Fact sheets: bundled payments for care improvement initiative fact sheet. Centers Medicare Medicaid Serv. Available at: http://www.cms.gov/ Newsroom?mediaReleaseDatabase/Fact-Sheets/2014-Fact-sheets-items/ 2014-01-30-2.html. Accessed May 16, 2014. 5. Froimson MI, Rana A, White RE Jr, et al. Bundled payments for care improvement initiative: the next evolution of payment formulations:

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23.

24. 25. 26. 27.

AAHKS Bundled Payment Task Force. J Arthroplasty. 2013;28 (8 suppl):157–165. Altman SH. The lessons of Medicare’s prospective payment system show that the bundled payment program faces challenges. Health Aff. 2012;31: 1923–1930. Steele JR, Reilly JD. Bundled payments: bundled risk or bundled reward? J Am Coll Radiol. 2010;7:43–49. Hemmila MR, Jakubus JL, Maggio PM, et al. Real money: complications and hospital costs in trauma patients. Surgery. 2008;144:307–316. SooHoo NF, Farng E, Chambers L, et al. Comparison of complication rates between hemiarthroplasty and total hip arthroplasty for intracapsular hip fractures. Orthopedics. 2013;36:e384–e389. Poh KS, Lingaraj K. Complications and their risk factors following hip fracture surgery. J Orthop Surg. 2013;21:154–157. Anakwe RE, Middleton SD, Jenkins PJ, et al. Total hip replacement in patients with hip fracture: a matched cohort study. J Trauma Acute Care Surg. 2012;73:738–742. Sathiyakumar V, Thakore RV, Ihejirika RC, et al. Distal tibia fractures and medial plating: factors influencing re-operation. Int Orthop. 2014;38: 1483–1488. Li Y, Jiang X, Guo Q, et al. Treatment of distal shaft fractures by three different surgical methods: a randomized, prospective study. Int Orthop. 2014;38:1261–1267. Hiesterman TG, Shafiq BX, Cole PA. Intramedullary nailing of extraarticular proximal tibia fractures. J Am Acad Orthop Surg. 2011;19: 690–700. Mahabier KC, Vogels LM, Punt BJ, et al. Humeral shaft fractures: retrospective results of non-operative and operative treatment of 186 patients. Injury. 2013;44:427–430. Baltov A, Mihail R, Dian E. Complications after interlocking intramedullary nailing of humeral shaft fractures. Injury. 2014;45(suppl 1): S9–S15. Yang H, Li Z, Zhou F, et al. A prospective clinical study of proximal humerus fractures treated with a locking proximal humerus plate. J Orthop Trauma. 2011;25:11–78. AAOS Orthopaedic Surgeon Census. American Academy of Orthopaedic Surgeons. 2010. Available at: http://www.aaos.org/research/orthocensus/ census.asp. Accessed May 16, 2014. Molina CS, Thakore RV, Blumer A, et al. Use of the national surgical quality improvement program in orthopaedic surgery. Clin Orthop Relat Res. 2014. Epub ahead of print. Pugely AJ, Martin CT, Gao Y, et al. A risk calculator for short-term morbidity and mortality after hip fracture surgery. J Orthop Trauma. 2014;28:63–69. Cutler DM, Ghosh K. The potential for cost savings through bundled episode payments. N Engl J Med. 2012;366:1075–1077. Torio CM, Andrews RM. The national hospital bill: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.pdf. Accessed May 16, 2014. Bundled payments for care improvement (BPCI) initiative: general information. Centers for Medicare & Medicaid Services. Available at: http://innovation.cms.gov/initiatives/bundled-payments. Accessed May 16, 2014. Birkmeyer JD, Gust C, Baser O, et al. Medicare payments for common inpatient procedures: implications for episode-based payment bundling. Health Serv Res. 2010;45(6 Pt 1):1783–1795. Fern KT, Smith JT, Zee B, et al. Trauma patients with multiple extremity injuries: resource utilization and long-term outcome in relation to injury severity scores. J Trauma. 1998;45:489–494. Pugely AJ, Callaghan JJ, Martin CT, et al. Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: analysis from the ACS-NSQIP. J Arthroplasty. 2013;28:1499–1504. Martin CT, Gao Y, Pugely AJ, et al. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22:1667–1675.e1.

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Adverse Events in Orthopaedics: Is Trauma More Risky? An Analysis of the NSQIP Data.

As our healthcare system moves toward bundling payments, orthopaedic trauma surgeons will be increasingly benchmarked on perioperative complications. ...
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