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In 2014, Maryland implemented an experimental reimbursement model, Global Budget Revenue (GBR). This model provided hospitals with a capitated annual budget each fiscal year to use toward all services, regardless of payer. Goals of GBR include reductions in cost, improvements in care quality, and increased access for patients to high-volume procedures, such as total knee arthroplasty (TKA). We assessed demographics and outcomes among patients with low incomes and patients of racial minority groups in Maryland who underwent TKA before and after GBR implementation. Patients undergoing TKAs from 2011 to 2016 were queried from the Maryland State Inpatient Database, resulting in 71,066 patients. There were 13,722 patients with low incomes and 19,846 patients of racial minority groups. The chi-square test was used for sex, income, insurance, Charlson Comorbidity Index, and morbid obesity, with the Student's t test being reserved for age before and after GBR. The proportion of patients with low incomes decreased the year before GBR but increased with GBR and maintained ( P <.001). The proportion of patients of racial minority groups increased the year before GBR implementation, decreased slightly, and then maintained ( P <.001). Mean cost decreased for both cohorts of patients (both P <.001). Discharges to home increased for both cohorts ( P <.001), while length of stay decreased (both P <.001). Global Budget Revenue decreased cost while improving outcomes for TKA patients post-GBR. Patients with low incomes have not increased their use of TKA, contrary to patients of racial minority groups. This suggests that barriers remain. Further follow-up of GBR performance in subsequent years will increase understanding of the sustainability of this trend and the degree to which any increase in access is dependent on the implementation of the Affordable Care Act. [ Orthopedics . 2022;45(1):e11–e16.]

No abstract

Introduction: Clinical laboratories offer several multipurpose tests, such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), which are not intended to diagnose any specific disease but are used by clinicians in multiple fields. The results and laboratory interpretation (normal/abnormal) of these multipurpose tests are based on laboratory-reported normal thresholds, which vary across clinical laboratories. In 2018, the International Consensus Meeting on Musculoskeletal Infection (2018 ICM) provided a gold-standard definition to diagnose periprosthetic joint infection (PJI) which included many multipurpose laboratory tests, along with thresholds optimized to diagnose PJI. The discrepancy between laboratory-reported normal thresholds and 2018 ICM-recommended PJI-optimized test thresholds has never been studied. The purpose of this study was to assess the existing variation in laboratory-reported normal thresholds for tests commonly used to diagnose PJI and evaluate the potential diagnostic impact of using laboratory-reported normal thresholds instead of 2018 ICM-recommended PJI-optimized thresholds.Methods: Clinical laboratories (N=85) were surveyed to determine the laboratory-reported units of measure and normal thresholds for common multipurpose tests to diagnose PJI, including the ESR, CRP, D-dimer, synovial fluid white blood cells (SF-WBC), and polymorphonuclear cell percent (SF-PMN%). The variability of units of measure and normal thresholds for each test was then assessed among the 85 included clinical laboratories. A representative dataset from patients awaiting a revision arthroplasty was used to determine the clinical significance of the existing discrepancy between laboratory-reported normal test interpretations and 2018 ICM-recommended PJI-optimized test interpretations.Results: Two units of measure for the CRP and six units of measure for the D-dimer were observed, with only 59% of laboratories reporting the CRP in terms of mg/L and only 16% reporting the D-dimer in ng/ml, as needed to utilize the 2018 ICM definition of PJI. Across clinical laboratories surveyed, the mean laboratoryreported normal thresholds for the ESR (20 mm/h), CRP (7.69 mg/L), D-dimer (500 ng/mL), SF-WBC (5 cells/uL), and SF-PMN% (25%) were substantially lower than the 2018 ICM-recommended PJI-optimized thresholds of 30 mm/h, 10 mg/L, 860 ng/mL, 3,000 cells/uL, and 70%, respectively. Interpretation of test results from a representative PJI dataset using each laboratory's normal test thresholds yielded mean falsepositive rates of 14% (ESR), 18% (CRP), 42% (D-dimer), 93% (SF-WBC), and 36% (SF-PMN%) versus the ICMrecommended PJI-optimized thresholds.Conclusion: When reporting the results for multipurpose laboratory tests, such as the ESR, CRP, D-dimer, SF-WBC, and SF-PMN%, clinical laboratories utilize laboratory-reported units of measure and normal thresholds that are not intended to diagnose PJI, and therefore may not match the 2018 ICM recommendations. Our findings reveal that laboratory-reported normal thresh...