Resource utilization of total knee arthroplasty patients cared for on specialty orthopedic surgery units

Sustainable surgical practices: A comprehensive approach to reducing environmental impact

This paper presents a comprehensive overview of the environmental impact of surgical procedures and highlights potential strategies to reduce the associated greenhouse gas emissions. We discuss procurement, waste management, and energy consumption, providing examples of successful interventions in each area. We also emphasize the importance of adopting the Green Theatre Checklist as a useful tool for clinicians aiming to implement sustainable surgical practices.

The Environmental Impact of Spine Surgery and the Path to Sustainability

STUDY DESIGN

Narrative literature review.

OBJECTIVE

The aim of this study was to review published literature discussing sustainable health care and to identify aspects that pertain to spine surgery.

SUMMARY OF BACKGROUND DATA

In recent years, research has investigated the contribution of surgical specialties to climate change. To our knowledge, no article has yet been published discussing the impact specific to spinal procedures and possible mitigation strategies.

METHODS

A literature search was performed for the present study on relevant terms across four electronic databases. References of included studies were also investigated.

RESULTS

Spine surgery has a growing environmental impact. Investigations of analogous specialties find that procurement is the single largest source of emissions. Carbon-conscious procurement strategies will be needed to mitigate this fully, but clinicians can best reduce their impact by adopting a minimalist approach when using surgical items. Reduced wastage of disposable goods and increased recycling are beneficial. Technology can aid remote access to clinicians, and also enable patient education.

CONCLUSIONS

Spine-surgery-specific research is warranted to evaluate its carbon footprint. A broad range of measures is recommended from preventative medicine to preoperative, intraoperative, and postoperative spine care.

LEVEL OF EVIDENCE

5.

Cost Analysis of Single-Level Lumbar Fusions

STUDY DESIGN

Cost analysis of a retrospectively identified cohort of patients who had undergone primary single-level lumbar fusion at a single institution's orthopedic or neurosurgery department.

OBJECTIVE

The purpose of this article is to analyze the determinants of direct costs for single-level lumbar fusions and identify potential areas for cost reduction.

METHODS

Adult patients who underwent primary single-level lumbar fusion from fiscal years 2008 to 2012 were identified via administrative and departmental databases and were eligible for inclusion. Patients were excluded if they underwent multiple surgeries, had previous surgery at the same anatomic region, underwent corpectomy, kyphectomy, disc replacement, surgery for tumor or infection, or had incomplete cost data. Demographic data, surgical data, and direct cost data in the categories of supplies, services, room and care, and pharmacy, was collected for each patient.

RESULTS

The cohort included 532 patients. Direct costs ranged from $8286 to $73 727 (median = $21 781; mean = $22 890 ± $6323). Surgical approach was an important determinant of cost. The mean direct cost was highest for the circumferential approach and lowest for posterior instrumented spinal fusions without an interbody cage. The difference in mean direct cost between transforaminal lumbar interbody fusions, anterior lumbar interbody fusions, and lateral transpsoas fusions was not statistically significant. Surgical supplies accounted for 44% of direct costs. Spinal implants were the primary component of supply costs (84.9%). Services accounted for 38% of direct costs and were highly dependent on operative time. Comorbidities were an important contributor to variance in the cost of care as evidenced by high variance in pharmacy costs and length of stay related to their management.

CONCLUSION

The costs of spinal surgeries are highly variable. Important cost drivers in our analysis included surgical approach, implants, operating room time, and length of hospital stay. Areas of high cost and high variance offer potential targets for cost savings and quality improvements.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A Preoperative Scale for Determining Surgical Readmission Risk After Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is one of the most common orthopaedic procedures performed in the U.S. The purpose of this study was to develop and verify a scale to preoperatively stratify a patient's risk of being readmitted to the hospital following a TKA.

METHODS

Discharge data on 433,638 patients from New York and California (derivation cohort) and 269,934 patients from Florida and Washington (validation cohort) who underwent TKA were collected from the State Inpatient Database, a part of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality (2006 to 2011). Demographic and clinical characteristics of patients were abstracted and analyzed to develop the Readmission After Total Knee Arthroplasty (RATKA) Scale.

RESULTS

Overall 30-day readmission rates in the derivation and validation cohorts were 5.11% and 4.98%, respectively. The following factors were significantly associated with increased 30-day readmission rates in the derivation cohort: age of 41 to 50 years (odds ratio [OR] = 1.13), age of 71 to 80 years (OR = 1.21), age of 81 to 90 years (OR = 1.70), male sex (OR = 1.19), African-American race (OR = 1.37), "other" race/ethnicity (OR = 1.08), Medicaid payer (OR = 1.43), Medicare payer (OR = 1.27), anemia (OR = 1.19), chronic obstructive pulmonary disease (OR = 1.29), coagulopathy (OR = 1.22), congestive heart failure (OR = 1.64), diabetes (OR = 1.19), fluid and electrolyte disorder (OR = 1.25), hypertension (OR = 1.10), liver disease (OR = 1.27), renal failure (OR = 1.33), and rheumatoid arthritis (OR = 1.14). These factors were used to create the RATKA Scale. The RATKA score was then used to define 3 levels of risk for readmission: low (RATKA score of <13; 3.7% readmission rate), moderate (RATKA score of 13 to 16; 5.4% readmission rate), and high (RATKA score of >16; 7.6% readmission rate). The relative risk of readmission was 2.06 for the high-risk group compared with the low-risk group.

CONCLUSIONS

The RATKA Scale derived from patient data from the derivation cohort was reliably able to explain readmission variability after TKA for patients in the validation cohort at a rate of >95%. Models such as the RATKA Scale will enable identification of the risk of readmission following TKA based on a patient's risk profile prior to surgery.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Health Care Reform: Impact on Total Joint Replacement

The US health care system has been fragmented for more than 40 years; this model created a need for modification. Sociopoliticomedical system-related factors led to the Affordable Care Act (ACA) and a restructuring of health care provision/delivery. The ACA increases access to high-quality "affordable care" under cost-effective measures. This article provides a comprehensive review of health reform and the motivating factors that drive policy to empower arthroplasty providers to effectively advocate for the field of orthopedics as a whole, and the patients served.

The effect of obesity on theatre utilisation time during primary hip and knee replacements

Introduction :

The aim of this study is to assess the effect of body mass index (BMI) and body weight on theatre utilisation time during primary total hip (THR) and knee replacements (TKR).

Methods :

A total of 1859 cases were included (820 THR and 1039 TKR). Patients were divided into groups based on BMI and body weight. The time interval from ‘starting anaesthesia’ to ‘transfer back to recovery’ was used as total theatre time. Hierarchal regression analysis was then used to study the effect of BMI and body weight while controlling the effect of any confounding variables.

Results :

In THR cases, the median theatre time was significantly different between BMI and body weight subgroups (p=0.001). In TKR cases, the median theatre time was more significantly different between weight subgroups (p<0.001) than BMI subgroups (p=0.021). Regression analysis showed that only weight remained a significant predictor (p=0.018) of theatre time in THR cases after controlling for other variables. In TKR cases, body weight and BMI were not predictors of theatre time after controlling for other variables.

Conclusion :

Body weight is a significant predictor of theatre time during THR. Neither weight nor BMI predicted theatre time during TKR.

Association between muscle atrophy/weakness and health care costs and utilization among patients receiving total knee replacement surgery: a retrospective cohort study

Purpose

The aim of the study reported here was to examine health care resource utilization, costs, and risk of rehospitalization for total knee replacement (TKR) patients with and without muscle atrophy/weakness (MAW).

Patients and methods

Individuals aged 50–64 years with commercial insurance or 65+ years with Medicare Supplemental Insurance (Medicare) who had a hospitalization for TKR between January 1, 2006 and September 30, 2009 were identified from a large US claims database. First hospitalization for TKR was defined as the index stay. All patients were classified into three cohorts according to when MAW was diagnosed relative to TKR: pre-MAW, post-MAW, and no MAW. The association between MAW and health care costs over the 12-month post-index period and the probability of rehospitalization were assessed via multivariate regressions

Results

The study sample included 53,696 Medicare and 46,058 commercial insurance TKR patients. Controlling for cross-cohort differences, both the pre- and post-MAW cohorts had significantly higher total health care costs (Medicare US$4,201 and US$9,404 higher, commercial insurance US$2,737 and US$6,640 higher, respectively) than the no MAW cohort (all P < 0.05). The post-MAW cohort in both populations was also more likely to have any all-cause or replacement-related rehospitalization compared with the no MAW cohort.

Conclusion

Among US patients undergoing TKR, those with MAW had higher health care utilization and costs than patients without MAW.

Increased operating room time in patients with obesity during primary total knee arthroplasty: conflicts for scheduling

Obesity is associated with increased complications related to total knee arthroplasty (TKA), but the relationship between body mass index (BMI) and operating room time during TKA is unknown. A total of 454 unilateral primary TKAs (2005-2009) were reviewed and categorized by BMI (normal weight, 18.5-25 kg/m(2); overweight, 25-30 kg/m(2); obese class I, 30-<35 kg/m(2); class II, 35-40 kg/m(2); class III, >40 kg/m(2)). Intraoperative time measurements (total room time, anesthesia induction time, tourniquet time, closing time, surgery time) were compared across the BMI groups. Comparing normal weight to obese class III, time differences were significant in total room time (24 minutes, P < .01), surgery time (16 minutes, P < .01), tourniquet time (7.5 minutes, P < .01), and closure time (8 minutes, P < .01). Armed with this information, BMI can be used to better allocate operating room time for TKA.

Body mass index and the impact on hospital resource use in patients undergoing total knee arthroplasty

We identified all total knee arthroplasty patients between 1996 and 2004 and classified them by preoperative body mass index (BMI) as normal (BMI, 18.5-24.9 kg/m(2)), overweight (BMI, 25.0-29.9 kg/m(2)), obese (30-34.9 kg/m(2)), or morbidly obese (≥ 35.0 kg/m(2)). Of 5521 patients, 769 had a normal BMI, 1938 were overweight, 1539 were obese, and 1275 were morbidly obese. Adjusted length of stay was no different between normal (4.85 days), overweight (4.84 days), obese (4.86 days), or morbidly obese patients (4.93 days) (P = .30). Overall costs were similar among normal ($15,386), overweight ($15,430), obese ($15,646), or morbidly obese patients ($15,752) (P = .24). Postsurgical costs were no different among normal ($9860), overweight ($9889), obese ($10,063), or morbidly obese patients ($10,136) (P = .44). Our results suggest that increased BMI does not lead to increased hospital resource use for total knee arthroplasty.