Richard Iorio - Academia.edu (original) (raw)

Papers by Richard Iorio

Our current healthcare climate is rapidly changing. However, the transition from a fee-for-servic... more Our current healthcare climate is rapidly changing. However, the transition from a fee-for-service (FFS) model to a bundled payment system appears certain. For total joint arthroplasty (TJA) providers, this change must be embraced as the potential benefits to a bundled payment system are clear and abundant. In this chapter, we will provide an overview of factors essential for effectively transitioning to a bundled payment system. Primarily, we will discuss key steps in creating a successful outpatient total joint arthroplasty (OTJA) experience, which is vitally important in the setting of a bundled payment system. We will discuss the relevant stakeholders, patient selection, and standardization processes, as well as physician partner buy-in, among other important factors. Change is inevitable, but must be embraced to ensure long-term success. This chapter provides a solid framework for the OTJA provider looking to succeed in our new healthcare landscape.

Clinical Orthopaedics and Related Research, 2012

Background Modular, metal-backed tibial (MBT) components are associated with locking mechanism dy... more Background Modular, metal-backed tibial (MBT) components are associated with locking mechanism dysfunction, breakage, backside wear, and osteolysis, which compromise survivorship. All-polyethylene tibial (APT) components eliminate problems associated with MBTs, but, historically, APT utilization has generally been limited to older, less active patients. However, it is unclear whether APT utilization can be expanded to a nonselected patient population. Questions/purposes We therefore determined the survivorship of APT components compared with MBT components in a non-age-or activity-selected population who underwent TKA. Methods Using a longitudinal database, we identified 775 patients with primary TKAs utilizing a single implant design between 1999 and 2007. Of these, 558 (72%) patients had APT components (APT2), while 217 (28%) patients with tibial bone loss or defects, contralateral MBT components, or a BMI of greater than 37.5 received MBT components. We determined the survivorship in the two groups. The minimum followup was 2 years for both groups (mean ± SD: MBT, 80 ± 29 months; APT, 63 ± 27 months). The APT group was older (average age: APT2, 70 years; MBT, 64.7 years) and had a lower BMI than the MBT group (APT2, 30.8; MBT, 33.8). Results Survivorship, as defined by revision for any reason, was 99% for the APT group and 97% for the MBT group. There were four (2%) tibial failures in the MBT group in patients with a BMI of greater than 40. There were no revisions for loosening or osteolysis in the APT group. Conclusion APT implants perform as well as MBT implants in a non-age-or activity-selected TKA population with a BMI of less than 37.5. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. One author (WLH) has a product development agreement with DePuy Orthopaedics Inc, a Johnson and Johnson company (Warsaw, IN, USA). No institutional support was received for this study. Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

Jbjs reviews, Mar 1, 2019

» The U.S. Patient Protection and Affordable Care Act (Affordable Care Act or "Obamacare") repres... more » The U.S. Patient Protection and Affordable Care Act (Affordable Care Act or "Obamacare") represents a comprehensive initiative to improve health insurance coverage, affordability, and access, while minimizing health-care spending and improving upon the quality of care provided. » The U.S. Center for Medicare & Medicaid Innovation, one of the important components of the Affordable Care Act, has developed new innovative payment and service delivery models, commonly referred to as alternative payment models, to reduce health-care expenditures. » Alternative payment models have undergone several iterations over the past decade, including the Acute Care Episode (ACE) demonstration, the Bundled Payments for Care Improvement (BPCI) initiative, the BPCI Advanced initiative, and the Comprehensive Care for Joint Replacement (CJR) program. » The goal of this article was to review the logistics, performance, and limitations of these 4 alternative payment models and to discuss what the future of health-care reimbursements may hold.

Bone, Feb 1, 2003

In adult human beings, remodeling creates nearly all of new bone tissue. However, Frost hypothesi... more In adult human beings, remodeling creates nearly all of new bone tissue. However, Frost hypothesized that modeling can go on in trabeculae throughout life. As this hypothesis has not been verified, we looked for histologic evidence of trabecular modeling (minimodeling) during bone histomorphometry of transiliac bone biopsy specimens obtained from 34 patients (age range, 38–81 years; mean age, 58.4 years;

Journal of Arthroplasty, Nov 1, 2021

Journal of Bone and Joint Surgery, American Volume, Sep 16, 2020

Journal of Arthroplasty, Aug 1, 2022

Moving THA off of the Inpatient Only (IPO) List for Center of Medicaid and Medicare Services (CMS... more Moving THA off of the Inpatient Only (IPO) List for Center of Medicaid and Medicare Services (CMS) beneficiaries and the Covid-19 pandemic has caused a shift in delivery away from inpatient services and a decrease in demand. Medicare payments dramatically declined from 2019 to 2020. LOS decreases and shift to outpatient designations were accelerated by IPO list changes and Covid-19 issues. The percentage of SDD cases also increased. Other metrics favorable to decreased spending by CMS were increased discharge to home and decreased volume. These changes have a profound impact on surgeon-hospital relationships and surgeon compensation.

Clinical Orthopaedics and Related Research, Feb 1, 2017

Background Hip fractures are a major public health concern. For displaced femoral neck fractures,... more Background Hip fractures are a major public health concern. For displaced femoral neck fractures, the needs for medical services during hospitalization and extending beyond hospital discharge after total hip arthroplasty (THA) may be different than the needs after THA performed for osteoarthritis (OA), yet these differences are largely uncharacterized, and the Medicare Severity Diagnosis-Related Groups system does not distinguish between THA performed for fracture and OA. Questions/purposes (1) What are the differences in inhospital and 30-day postoperative clinical outcomes for THA performed for femoral neck fracture versus OA? (2) Is a patient's fracture status, that is whether or not a patient has a femoral neck fracture, associated with differences in in-hospital and 30-day postoperative clinical outcomes after THA? Methods The National Surgical Quality Improvement Program (NSQIP) database, which contains outcomes for surgical patients up to 30 days after discharge, was used to identify patients undergoing THA for OA and femoral neck fracture. OA and fracture cohorts were matched one-to-one using propensity scores based on age, gender, American Society of Anesthesiologists grade, and medical comorbidities. Propensity scores represented the conditional probabilities for each patient having a femoral neck fracture based on their individual characteristics, excluding their actual fracture status. Outcomes of interest included operative time, length of stay (LOS), complications, transfusion, discharge destination, and readmission. There were 42,692 patients identified (41,739 OA; 953 femoral neck fractures) with 953 patients in each group for the matched analysis.

PubMed, Dec 23, 2016

Multimodal pain control strategies are crucial in reducing opioid use and delivering effective pa... more Multimodal pain control strategies are crucial in reducing opioid use and delivering effective pain management to facilitate improved surgical outcomes. The utility of liposomal bupivacaine in enabling effective pain control in multimodal strategies has been demonstrated in several studies, but others have found the value of liposomal bupivacaine in such approaches to be insignificant. At New York University Langone Medical Center, liposomal bupivacaine injection and femoral nerve block were compared in their delivery of efficacious and cost-effective multimodal analgesia among patients undergoing total joint arthroplasty (TJA). Retrospective analysis revealed that including liposomal bupivacaine in a multimodal pain control protocol for TJA resulted in improved quality and efficiency metrics, decreased narcotic use, and faster mobilization, all relative to femoral nerve block, and without a significant increase in admission costs. In addition, liposomal bupivacaine use was associated with elimination of the need for patient-controlled analgesia in TJA. Thus, at Langone Medical Center, the introduction of liposomal bupivacaine to TJA has been instrumental in achieving adequate pain control, delivering high-level quality of care, and controlling costs.

Clinical Orthopaedics and Related Research, Jun 1, 2016

Journal of Arthroplasty, Mar 1, 2015

Health Affairs, Dec 1, 2019

Journal of Arthroplasty, May 1, 2016

Journal of the American Academy of Orthopaedic Surgeons, Apr 6, 2021

The modern era is an increasingly digital and connected world. Most of the Americans now use a sm... more The modern era is an increasingly digital and connected world. Most of the Americans now use a smartphone irrespective of age or income level. As smartphone technologies become ubiquitous, there is tremendous interest and growth in mobile health applications. One segment of these new technologies are the so-called patient engagement platforms. These technologies present a host of features that may improve care. This article provides an introduction to this growing technology sector, offers insight into what they may offer patients and surgeons, and discusses how to evaluate various platforms.

$Research paper thumbnail of Displaced femoral neck fractures in the elderly: Methods of treatment with analysis of outcomes and cost effectiveness$

Journal of Arthroplasty, Feb 1, 1998

A retrospective analysis of patients undergoing total hip replacement and total knee replacement ... more A retrospective analysis of patients undergoing total hip replacement and total knee replacement was performed to evaluate the cost effectiveness of autologous blood donation compared to the use of aUogenic blood. Fiftyfour patients received a primary total hip arthroplasty (THA) and fortytwo patients received a primary total knee arthroplasty (TKA). Data collection included the number of units of blood donated, number of autologous units transfused, and number of allogenic units transfused. Charge data was gathered from the hospital and the blood bank and used as surrogate for cost values. The direct cost to the hospital for one unit of autologous blood is 101.00andforaflogenicbloodis101.00 and for aflogenic blood is 101.00andforaflogenicbloodis75.00. The cost to the blood bank for autologous blood is 102.50andthecostforallogenicbloodis102.50 and the cost for allogenic blood is 102.50andthecostforallogenicbloodis67.50. The utilization rate of autologous blood and the calculated cost to discard unused blood was added to the direct cost to determine the total cost of autologous blood. The risk of disease transmission was used to calculate the additional cost incurred with allogenic blood utilization, and also the difference in quality-adjusted life years between those patients receiving autologous blood vs. those receiving allogenic blood. For patients undergoing TH, A, 62% of the patients donated blood and 58% of the donors were reinfused without exposure to allogenic blood. For patients receiving TICA, 56% donated blood and of the donors, only 47% received reinfusion. With our utilization rate, the total cost for autologous blood was $564.

Current Opinion in Orthopaedics, Feb 1, 2007

Purpose of review This review describes current strategies to control the cost of total hip arthr... more Purpose of review This review describes current strategies to control the cost of total hip arthroplasty implants and operations. Recent findings Reductions in the utilization of hospital resources through clinical pathways, physician education and increased surgeon awareness have been effective in reducing the hospital costs associated with total hip arthroplasty. Cost reduction of total-hip-arthroplasty hospital expenses is directed at implant costs. Vendor discounting, price capping, demand matching/implant standardization, competitive bid purchasing and single-price/case-price purchasing are utilized by hospitals to control implant costs. Recently the US Department of Justice investigation of the orthopaedic implant companies, the development of Advanced Medical Technology Association (AdvaMed) ethical guidelines to govern the interaction between implant companies and orthopaedic surgeons, and the Health and Human Services' Office of the Inspector General's opinion favoring joint ventures/coordinated care arrangements/ gainsharing have given hospitals an incentive to align with orthopaedic surgeons to bring down hip-implant costs. Summary The current economic model for total hip arthroplasty is unsustainable. Technologic innovation, expanding indications, and an increasing patient population threaten to overwhelm the system from an economic perspective. Hospital and surgeon-coordinated care efforts are necessary to prevent system collapse and to continue cost efficient, high-quality care for patients needing hip replacement.

Journal of the American Academy of Orthopaedic Surgeons, Nov 1, 2015

Total joint arthroplasty is a highly successful surgical procedure for patients with painful arth... more Total joint arthroplasty is a highly successful surgical procedure for patients with painful arthritic joints. The increasing prevalence of the procedure is generating significant expenditures in the American healthcare system. Healthcare payers, specifically the Center for Medicare and Medicaid Services, currently target total joint arthroplasty as an area for healthcare cost-savings initiatives, resulting in increased scrutiny surrounding orthopaedic care, health resource utilization, and hospital readmissions. Identifying the complications associated with total hip and total knee arthroplasty that result in readmissions will be critically important for predictive modeling and for decreasing the number of readmissions following total joint arthroplasty. Additionally, improving perioperative optimization, providing seamless episodic care, and intensifying posthospital coordination of care may result in a decreasing number of unnecessary hospital readmissions. Identified modifiable risk factors that significantly contribute to poor clinical outcome following total joint arthroplasty include morbid obesity; poorly controlled diabetes and nutritional deficiencies; Staphylococcus aureus colonization; tobacco use; venous thromboembolic disease; cardiovascular disease; neurocognitive, psychological, and behavioral problems; and physical deconditioning and fall risk. Both clinical practice and research will be enhanced if there is standardization of defined total joint arthroplasty complications and utilization of stratification schemes to identify high-risk patients. Subsequently, clinical intervention would be warranted to address modifiable risk factors before proceeding with total joint arthroplasty. T otal joint arthroplasty (TJA) is a highly successful surgical procedure for patients with painful, arthritic joints. The prevalence of TJA has increased considerably; an estimated two million Americans are expected to receive a total hip arthroplasty (THA) or total knee arthroplasty (TKA) in 2020. 1 The rising volume of joint arthroplasties in this country generates significant expenditures to the American healthcare system, and healthcare payers are currently targeting TJA for healthcare cost-savings initiatives. The Center for Medicare and Medicaid Services (CMS) has targeted orthopaedics, specifically TJA, for evaluation and has begun penalizing hospitals for high readmission rates.