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Despite the increase in TAR utilization over time, TAR
utilization is still low compared with arthrodesis, which
suggests there may be potential impediments to the broader
adoption of TAR across hospitals. For example, TAR has
been shown to have a higher complication rate relative to
arthrodesis, which could serve as potential deterrent for
both surgeons and hospitals desiring to perform them.12
Although total ankle arthroplasty has been shown to be a
cost-effective procedure in comparison to conservative
management and ankle arthrodesis, complications such as
periprosthetic fracture, infection, and aseptic loosening all
have the potential to increase the overall financial burden of
performing TAR through additional hospitalizations and
surgeries.8,11,15,20 Implant costs may also increase the overall
financial burden of performing TAR and serve as a potential
impediment to its broader utilization. Little attention has
been devoted to investigating the determinants of TAR use
and evaluating the impact of the increased utilization of
TAR at the individual hospital level with respect to volume
and profitability. This study investigated the variation in
TAR utilization across hospitals, focusing on inpatient costs
particularly as it related to primary TAR, and the hospital
characteristics associated with that variation.
Methods
The primary data source was the 2011 and 2012 Medicare
Inpatient Limited Data Sets, which contained 100% of
Medicare fee-for-service claims submitted by inpatient
hospitals to the Centers for Medicare & Medicaid Services
(CMS).1 The study sample was limited to short-term acute
care hospitals that were paid under the Inpatient Prospective
Payment System (IPPS) in 2011 and 2012.1 In addition, we
used data from fiscal year (FY) 2010 cost reports7 to compute overall hospital all-payer margins. We used cost-tocharge ratios associated with overall services and
"implantable devices" obtained from cost reports to compute the cost of TAR surgery and the cost of the prosthesis,
respectively.
The FY2015 Impact File was used to gather data on hospital-level characteristics, such as bed size, census region,
teaching status, and urban/rural location. Hospital ownership data were obtained from the CMS Hospital Compare
Database.5 Finally, the Nationwide Inpatient Sample (NIS)13
data from 2011 was used to generate descriptive statistics
on all TAR patients covered by not only Medicare but also
Medicaid, private insurance, and the uninsured receiving
TAR and revision TAR. The 2011 NIS contains data on all
discharges for a sample of hospitals.13
Outcome and Explanatory Variables
Our outcome variables of interest were the likelihood of a
hospital performing a TAR and the volume of TAR cases,
Foot & Ankle International 38(6)
conditional on a hospital having performed at least 1 TAR
surgery in a year. TAR cases were identified using the
ICD-9 procedure code 81.56. The margin for each TAR surgery was computed as the difference between total payment
and total cost divided by payment. The margins for individual TAR surgeries within a hospital were averaged by
hospital to generate the TAR margin for each hospital. The
total Medicare payment for TAR consisted of the amount
paid by Medicare for the surgery, the beneficiary blood
deductible liability amount, the beneficiary inpatient
deductible amount, and the beneficiary Part A coinsurance
liability amount. Total costs were computed by multiplying
the total charge amount for TAR by the hospital all-payer
cost-to-charge ratio.
Hospital financial status was measured by overall hospital all-payer margins that are based on data from the
FY2010 cost report. The analyses also included several
hospital-level characteristics, such as census region, hospital ownership, rural/urban status, size, and teaching status. Teaching status was determined using resident-to-bed
ratio, with resident-to-bed ratios greater than or equal to
0.25 indicating major teaching hospital, between 0 and
0.25 indicating minor teaching hospital, and 0 indicating
nonteaching hospital.2 Hospitals were categorized into
small, medium, and large depending on whether their bed
count lay in the bottom, middle, or top third of the bed
size distribution among hospitals included in the
analysis.
The number of orthopedic surgeries (per 100 cases) performed were identified in the Medicare claims data using
ICD-9 procedure codes 76.XX-84.XX, 00.8X, and 00.9X.
In analyzing the relationship between a hospital's probability of performing TAR and orthopedic surgery volume, we
used the total number of orthopedic surgeries excluding surgeries related to ankle/foot, such as TAR (ICD-9 code
81.56), revision for TAR (ICD-9 code 81.59), and ankle
fusion (ICD-9 code 81.11). Hospitals where orthopedic surgeries excluding surgeries related to ankle/foot constitute at
least 50% of Medicare cases per year were identified as
orthopedic specialty hospitals.
For our descriptive analyses, we separated the total cost
of TAR surgery into the cost of prosthesis and the remaining
costs. To obtain the cost of prosthesis, we first identified the
prosthesis charges among all TAR cases using revenue center code 0278. The cost of primary and revision TAR was
calculated by multiplying the total charges for the surgery
by cost-to-charge ratio for overall services for each hospital. For cases involving prostheses, we multiplied the charge
amount associated with the prosthesis by the cost center
"implantable devices" cost-to-charge ratio obtained from
the cost report for each hospital. No identifiable patient
information was obtained from any of the databases
searches, and as such, institutional review board approval
was waived.
Table of Contents for the Digital Edition of Foot & Ankle International - June 2017
Contents
Foot & Ankle International - June 2017 - Intro
Foot & Ankle International - June 2017 - Cover1
Foot & Ankle International - June 2017 - Cover2
Foot & Ankle International - June 2017 - i
Foot & Ankle International - June 2017 - ii
Foot & Ankle International - June 2017 - Contents
Foot & Ankle International - June 2017 - iv
Foot & Ankle International - June 2017 - v
Foot & Ankle International - June 2017 - vi
Foot & Ankle International - June 2017 - vii
Foot & Ankle International - June 2017 - viii
Foot & Ankle International - June 2017 - 1A
Foot & Ankle International - June 2017 - 1B
Foot & Ankle International - June 2017 - ix
Foot & Ankle International - June 2017 - x
Foot & Ankle International - June 2017 - xi
Foot & Ankle International - June 2017 - xii
Foot & Ankle International - June 2017 - 2A
Foot & Ankle International - June 2017 - 2B
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Foot & Ankle International - June 2017 - xv
Foot & Ankle International - June 2017 - xvi
Foot & Ankle International - June 2017 - 3A
Foot & Ankle International - June 2017 - 3B
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Foot & Ankle International - June 2017 - CT1
Foot & Ankle International - June 2017 - CT2
Foot & Ankle International - June 2017 - 4A
Foot & Ankle International - June 2017 - 4B
Foot & Ankle International - June 2017 - Cover3
Foot & Ankle International - June 2017 - Cover4
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