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Trends in Reimbursement for One- versus Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection
Enrico M Forlenza1, Joseph Serino2, Kayla Hietpas3
1Rush University Medical Center, Department of Orthopaedic Surgery, Chicago, Illinois.
Background:
Emerging evidence suggests similar efficacy of one- and two-stage revision for periprosthetic joint infection (PJI). However, there is concern that extended surgical time and lower reimbursement for one-stage exchange may disincentivize surgeons from performing this procedure.
Methods:
Reimbursement data from 200 patients enrolled in a randomized controlled trial evaluating one-versus two-stage exchange for PJI between 2016 and 2022 was collected. The final cohort consisted of 98 patients undergoing one-stage exchange and 101 patients undergoing two-stage exchange. There was one patient excluded from the final analysis due to incomplete reimbursement data. Reimbursements were converted to 2022 inflation-adjusted dollars. The mean reimbursements for one- and two-stage exchanges were compared, and subgroup analyses based on procedure type (total hip arthroplasty or total knee arthroplasty), insurance status (Medicare or private), and Current Procedural Terminology codes were performed. A separate opportunity cost analysis was performed to determine the theoretical cumulative reimbursement surgeons could expect after treating 10 cases of PJI via either one- or two-stage exchange.
Results:
The mean combined reimbursement for a two-stage exchange was significantly greater than for a one-stage exchange ($4,342.40 versus $3,382.40; P < 0.001). The Current Procedural Terminology codes 27487/27,488 and 27,091/27,134, when billed together, consistently yielded the greatest reimbursement for one-stage exchange knee and hip procedures, respectively. Total operative time of a one-stage exchange was lower by 43 minutes, potentially allowing surgeons to perform more primary arthroplasties, equalizing total surgeon reimbursement.
Conclusions:
Reimbursement for a one-stage exchange is lagging behind a two-stage exchange; however, the efficiency of performing one procedure rather than two could lead to an equalization of total reimbursement. In an era of decreased surgical fees, a 28% discrepancy in reimbursement could conceivably discourage the usage of a potentially superior evidence-based treatment.
Insights
One-stage revision for periprosthetic joint infection (PJI) offers similar efficacy but lower reimbursement than two-stage. Despite financial disparities, the efficiency of one-stage procedures may equalize total surgeon earnings, potentially encouraging its use.
Area of Science:
- Orthopedic surgery
- Infectious disease management
Background:
- Periprosthetic joint infection (PJI) management often involves one- or two-stage revision surgery.
- Emerging evidence suggests comparable efficacy between one- and two-stage revision for PJI.
- Concerns exist regarding lower reimbursement and extended surgical times for one-stage procedures potentially limiting surgeon adoption.
Purpose of the Study:
- To compare the financial reimbursement between one-stage and two-stage revision surgeries for PJI.
- To analyze the impact of reimbursement on the adoption of one-stage PJI revision.
- To assess the potential for increased surgeon efficiency to offset lower per-procedure reimbursement in one-stage PJI revision.
Main Methods:
- A randomized controlled trial cohort of 199 patients undergoing one-stage (98) or two-stage (101) PJI revision was analyzed.
- Reimbursement data was collected from 2016-2022 and adjusted for 2022 inflation.
- Subgroup analyses included procedure type (THA/TKA), insurance, and CPT codes, with an opportunity cost analysis performed.
Main Results:
- Two-stage exchange yielded significantly higher mean reimbursement ($4,342.40) than one-stage exchange ($3,382.40; P < 0.001).
- Specific CPT codes were identified for maximizing one-stage reimbursement in hip and knee revisions.
- One-stage exchange reduced operative time by 43 minutes, potentially allowing for more procedures and equalizing total surgeon reimbursement.
Conclusions:
- A significant reimbursement gap exists between one-stage and two-stage PJI revision, with one-stage yielding 28% less.
- The increased efficiency of one-stage procedures may lead to comparable overall surgeon reimbursement.
- Discrepancies in reimbursement may discourage the use of the potentially superior, evidence-based one-stage PJI revision approach.
