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Balachandran M, Prabhakar S, Zhang W, Parks M, Ma Y. Racial and Ethnic Disparities in Primary Total Knee Arthroplasty Outcomes: A Systematic Review and Meta-Analysis of Two Decades of Research. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02105-x. [PMID: 39158831 DOI: 10.1007/s40615-024-02105-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 07/11/2024] [Accepted: 07/22/2024] [Indexed: 08/20/2024]
Abstract
Racial disparities in outcomes following total knee arthroplasty (TKA) remain persistent. This systematic review and meta-analysis aims to comprehensively synthesize data between 2000-2020. An electronic search of studies was performed on PubMed, SCOPUS, and the Cochrane Library databases from January 1, 2000, and December 31, 2020. Random effects models were used to report unadjusted and adjusted estimates for a comprehensive list of care outcomes in TKA. 63 studies met PRISMA criteria. Black patients report greater odds of in-hospital mortality (odds ratio [OR]: 1.37, 95% CI: 1.00-1.59 (p = 0.049); adjusted OR [aOR]: 1.34, 95% CI: 1.09-1.64), in-hospital complications (OR: 1.31, 95% CI: 1.27-1.35), 30-day complications (aOR: 1.19, 95% CI: 1.07-1.33), infection (OR: 1.11, 95% CI: 1.07-1.16; aOR: 1.30, 95% CI: 1.16-1.46), bleeding (OR: 1.33, 95% CI: 1.03-1.71; aOR: 1.47, 95% CI: 1.23-1.75), peripheral vascular events (PVE) (aOR: 1.46, 95% CI: 1.11-1.92), length of stay (LOS) (OR: 1.20, 95% CI: 1.08-1.34), extended-LOS (aOR: 1.89, 95% CI: 1.53-2.33), discharge disposition (OR: 1.59, 95% CI: 1.29-1.96; aOR: 1.96, 95% CI: 1.70-2.25), 30-day (OR: 1.20, 95% CI: 1.13-1.27; aOR: 1.17 95% CI: 1.09-1.26) and 90-day (OR: 1.46, 95% CI: 1.17-1.82) readmission compared to White patients. Disparities in bleeding, extended-LOS, discharge disposition, PVE, and 30-day readmission were observed in Asian patients. Hispanic patients experienced disparities in extended LOS and discharge disposition, while Native-American patients had disparities in bleeding outcomes. Persistent racial disparities in TKA outcomes highlight a need for standardized outcome measures and comprehensive data collection across multiple racial groups to ensure greater healthy equity.
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Affiliation(s)
- Madhu Balachandran
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, D.C., USA
| | - Sarah Prabhakar
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Washington, D.C., USA
| | - Wei Zhang
- Department of Mathematics & Statistics, University of Arkansas, Little Rock, AZ, USA
| | - Michael Parks
- Hospital for Special Surgery, New York City, NY, USA
- Weill Cornell Medical College, Cornell University, New York City, NY, USA
| | - Yan Ma
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
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Treu EA, Blackburn BE, Archibeck MJ, Peters CL, Pelt CE, Gililland JM, Anderson LA. Risk Factors for Return to the Emergency Department and Readmission After Same-Day Discharge Total Joint Arthroplasty. J Arthroplasty 2024; 39:1967-1973. [PMID: 38458335 DOI: 10.1016/j.arth.2024.02.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Same-day discharge (SDD) after total joint arthroplasty (TJA) is safe and cost effective. However, benefits may be offset by the potential cost of emergency department (ED) visits and readmissions. We identified risk factors for return to the ED and readmission in patients who underwent SDD and inpatient (IP) stays after TJA. METHODS We performed a retrospective review of patients who underwent primary TJA at an academic institution over the course of one year. There were 1,708 consecutive TJAs (721 THA [total hip arthroplasty] and 987 TKA [total knee arthroplasty]) included. A SDD occurred after 1,199 (70%) TJAs, 523 THAs, and 676 TKAs. We compared the demographics and comorbidities of patients who have SDD or IP who stayed following TJA. We documented rates of return to the ED or readmission within 90 days of surgery. Cohorts were compared using the Student's t-test or Chi-square test. Significant findings were those with P value < .05. RESULTS The SDD cohort had a significantly higher rate of young, non-White men who had a lower body mass index and fewer comorbidities than the IP cohort. Rates of return to ED and readmission were similar between SDD and IP cohorts after TJA and similar between THA and TKA. Factors that significantly influenced return to ED included a higher American Society of Anaesthesiologists score (SDD, IP), a higher Charlson Comorbidity Index score (SDD, IP), a lower body mass index (IP), and a psychological diagnosis (SDD, IP). Factors that significantly influenced readmission rates included a higher American Society of Anaesthesiologists score (SDD), older age (SDD), and psychological diagnosis (SDD, IP). CONCLUSIONS Patients who discharged the same day after primary TJA have similar rates of return to the ED and readmission as those admitted as an IP. Patients who had a psychological diagnosis, and particularly a diagnosis of depression, are at higher risk for return to the ED and readmission after primary TJA, regardless of discharge the same-day or IP admission. Improved measures that attempt to further treat and optimize this patient population could reduce unnecessary postoperative ED visits.
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Affiliation(s)
- Emily A Treu
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | | | | | | | | | | | - Lucas A Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
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Bindi VE, Hones KM, Schoch BS, Hampton HL, Wright TW, King JJ, Hao KA. The influence of depression on clinical outcomes of total shoulder arthroplasty: a systematic Review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1757-1763. [PMID: 38526619 DOI: 10.1007/s00590-024-03911-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE Much of the current literature on total shoulder arthroplasty (TSA) has assessed the impact of preoperative medical comorbidities on postoperative clinical outcomes. The literature concerning the impact of psychological disorders such as depression on TSA has increased in popularity in recent years, but there lacks a thorough review of the influence of depression on postoperative pain and functional outcomes. METHODS We queried PubMed/MEDLINE and identified six clinical studies that evaluated the influence of a psychiatric diagnosis of depression on patient outcomes after TSA. Studies that discussed the impacts of depression on TSA, including PROs or adverse events in adults, were included. Studies focused on other psychologic pathology, non-TSA shoulder treatments, or TSA not for primary osteoarthritis were excluded. Non-clinical studies, systematic reviews, letters to the editor, commentaries, dissertations, books, and book chapters were excluded. RESULTS Three cohort studies described patient-reported pain and functional outcomes and three database studies assessed the risk of postoperative complications. Cohort studies demonstrated that the prevalence of depression in patients undergoing TSA decreased from preoperatively to 12-months postoperatively. Two studies demonstrated that depression is an independent predictor of less pre- to postoperative improvement in the ASES score at minimum 2-year follow-up; however, one study found the difference between patients with and without depression did not exceed the minimum clinically important difference. Database studies demonstrated that depression was associated with higher rates of blood transfusion (n = 1, OR = 1.8), anemia (n = 1, OR = 1.65), wound infection (n = 2, OR = 1.41-2.09), prosthetic revision (n = 1, OR = 1.92), and length of hospital stay (n = 3, LOS = 2.5-3 days). CONCLUSION Although patients with a preoperative diagnosis of depression undergoing TSA can achieve satisfactory relief of shoulder pain and restoration of function, they may experience poorer patient-reported outcomes and a higher risk of postoperative adverse events compared to their peers. Surgeons should be cognizant of the influence of depression in their patients to facilitate proper patient selection that maximizes patient satisfaction, function, and minimizes the risk of adverse events following TSA. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Victoria E Bindi
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Keegan M Hones
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, 3450 Hull Road, Gainesville, FL, 32611, USA
| | - Bradley S Schoch
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Hailey L Hampton
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, 3450 Hull Road, Gainesville, FL, 32611, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, 3450 Hull Road, Gainesville, FL, 32611, USA
| | - Joseph J King
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, 3450 Hull Road, Gainesville, FL, 32611, USA.
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
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Xu G, Zou X, Dong Y, Alhaskawi A, Zhou H, Ezzi SHA, Kota VG, Abdulla MHAH, Alenikova O, Abdalbary SA, Lu H. Advancements in autologous peripheral nerve transplantation care: a review of strategies and practices to facilitate recovery. Front Neurol 2024; 15:1330224. [PMID: 38523615 PMCID: PMC10959128 DOI: 10.3389/fneur.2024.1330224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/22/2024] [Indexed: 03/26/2024] Open
Abstract
Autologous peripheral nerve transplantation, a pioneering technique in nerve injury treatment, has demonstrated remarkable progress. We examine recent nursing strategies and methodologies tailored to various anatomical sites, highlighting their role in postoperative recovery enhancement. Encompassing brachial plexus, upper limb, and lower limb nerve transplantation care, this discussion underscores the importance of personalized rehabilitation plans, interdisciplinary collaboration, and innovative approaches like nerve electrical stimulation and nerve growth factor therapy. Moreover, the exploration extends to effective complication management and prevention strategies, encompassing infection control and pain management. Ultimately, the review concludes by emphasizing the advances achieved in autologous peripheral nerve transplantation care, showcasing the potential to optimize postoperative recovery through tailored and advanced practices.
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Affiliation(s)
- Guoying Xu
- Operating Theater, Shaoxing City Keqiao District Hospital of Traditional Chinese Medicine, Shaoxing, Zhejiang, China
| | - Xiaodi Zou
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Yanzhao Dong
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ahmad Alhaskawi
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Haiying Zhou
- Faculty of Medicine, School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | | | | | | | - Olga Alenikova
- Department of Neurology, Republican Research and Clinical Center of Neurology and Neurosurgery, Minsk, Belarus
| | - Sahar Ahmed Abdalbary
- Department of Orthopedic Physical Therapy, Faculty of Physical Therapy, Nahda University in Beni Suef, Beni Suef, Egypt
| | - Hui Lu
- Operating Theater, Shaoxing City Keqiao District Hospital of Traditional Chinese Medicine, Shaoxing, Zhejiang, China
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Quinlan ND, Hegde V, Bracey DN, Pollet A, Johnson RM, Dennis DA, Jennings JM. Prevalence of Depressive Symptoms in Aseptic Revision Total Knee Arthroplasty Based on the Mode of Failure. Arthroplast Today 2024; 25:101298. [PMID: 38313191 PMCID: PMC10834461 DOI: 10.1016/j.artd.2023.101298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/18/2023] [Accepted: 11/05/2023] [Indexed: 02/06/2024] Open
Abstract
Background Complications following total knee arthroplasty (TKA) that necessitate revision cause considerable psychological distress and symptoms of depression, which are linked to poorer postoperative outcomes, increased complications, and increased healthcare utilization. We aimed to identify the prevalence of mental health disorders and symptoms preoperatively and postoperatively in patients undergoing aseptic revision TKA and to stratify these patients based on their mechanism of failure. Methods All patients undergoing aseptic revision TKA from 2008 to 2019 with a minimum 1-year follow-up were retrospectively reviewed at a single institution. Patients (n = 394) were grouped based on 7 failure modes previously described. Patients were considered to have depressive symptoms if their Veterans RAND-12 mental component score was below 42. Preoperative and postoperative Veterans RAND-12 mental component scores at the latest follow-up were evaluated. Results Overall comparative prevalence of preoperative to postoperative depressive symptoms was 23.4%-18.8%. By mode of failure are as follows: arthrofibrosis (25.8%-16.7%), aseptic loosening (25.3%-18.9%), extensor mechanism disruption (25%-50%), failed unicompartmental knee arthroplasty (8.6%-14.3%), instability (25.7%-17.1%), osteolysis or polyethylene wear (23.1%-23.1%), and patellar failure (11.8%-23.5%). There was no difference in depressive symptoms among failure modes preoperatively (P = .376) or at the latest postoperative follow-up (P = .175). Conclusions The prevalence of depressive symptoms in revision TKA patients appears to be independent of failure mode. Surgeon awareness and screening for depressive symptoms in this patient population preoperatively with referral for potential treatment may improve early postoperative outcomes.
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Affiliation(s)
| | - Vishal Hegde
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel N. Bracey
- Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Aviva Pollet
- Colorado Joint Replacement at AdventHealth Porter, Denver, CO, USA
| | | | - Douglas A. Dennis
- Colorado Joint Replacement at AdventHealth Porter, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
| | - Jason M. Jennings
- Colorado Joint Replacement at AdventHealth Porter, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
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Byrne CT, Durst CR, Rezzadeh KT, Rockov ZA, Lee A, McKelvey KS, Spitzer AI, Rajaee SS. Preoperative Depression Is Associated With Increased Short-term Complications But Equivalent Long-term Outcomes in Total Knee Arthroplasty. Orthopedics 2024; 47:40-45. [PMID: 37276440 DOI: 10.3928/01477447-20230531-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Concomitant depression negatively impacts outcomes following total knee arthroplasty (TKA). Patient-Reported Outcomes Measurement Information System (PROMIS) surveys are validated measures that quantify depression, pain, and physical function. We hypothesized that higher preoperative PROMIS-depression scores would be associated with inferior outcomes following TKA. A total of 258 patients underwent primary TKA at a tertiary academic center between June 2018 and August 2020. PROMIS scores were collected preoperatively and at 6 weeks, 3 months, 1 year, and 2 years postoperatively. Patients with preoperative PROMIS depression scores of 55 or greater were considered PROMIS depressed (PD) and patients with scores less than 55 were considered not PROMIS depressed (ND). The primary outcomes were changes in PROMIS scores. Secondary outcomes included total and daily mean morphine milligram equivalents (MME) received during admission as well as 90-day hospital readmission and 2-year all-cause revision rates. There were 66 (25.58%) patients in the PD group and 192 (74.42%) in the ND group. Patients in the PD group had improved depression scores at all follow-up intervals (P<.001) and decreased pain scores at 1 year (P=.016). Both groups experienced similar changes in function scores at each follow-up interval. Patients in the PD group had higher total (P=.176) and daily (P=.433) mean MME use while admitted. Ninety-day hospital readmissions were higher in the PD group (P=.002). There were no differences in 2-year revision rates (P=.648). Preoperative PROMIS-depression scores of 55 or greater do not negatively impact postoperative function, depression, or pain, and patients with these scores have greater improvement in depression and pain at certain intervals. Patients in the PD group had higher readmission rates. [Orthopedics. 2024;47(1):40-45.].
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Warren SI, Pham NS, Foreman CW, Huddleston JI. Concentrated Economic Disadvantage Predicts Resource Utilization After Total Knee Arthroplasty. J Arthroplasty 2023; 38:2526-2530.e1. [PMID: 37595766 DOI: 10.1016/j.arth.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 08/04/2023] [Accepted: 08/06/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND The Index of Concentration at the Extremes (ICE), a measure of geographic socioeconomic polarization, predicts several health outcomes but has not been evaluated concerning total knee arthroplasty (TKA). This study evaluates ICE as a predictor of post-TKA resource utilization. METHODS Using the Healthcare Cost and Utilization Project's New York State database from 2016 to 2017, we retrospectively evaluated 57,426 patients ≥50 years undergoing primary TKA. The ICE values for extreme concentrations of income and race were calculated using United States Census Bureau data with the formula ICEi = (Pi-Di)/Ti where Pi, Di, and Ti are the number of households in the most privileged extreme, disadvantaged extreme, and total population in zip code i, respectively. Extremes of privilege and disadvantage were defined as ≥$150,000 versus <$25,000 for income and non-Hispanic White versus non-Hispanic Black for race. Association of ICE values, demographics, and comorbidities with 90-day readmission and 90-day emergency department (ED) visits was examined using multivariable analysis. RESULTS Overall 90-day readmission and ED visit rates were 12.8% and 9.4%, respectively. On multivariable analysis, the lowest ICEIncome quintile (concentrated poverty) predicted 90-day readmission (odds ratio 1.17, 95% confidence interval 1.05 to 1.30, P = .005) and 90-day ED visit (odds ratio 1.22, 95% confidence interval 1.08 to 1.38, P = .001). The ICERace was not predictive of either outcome. CONCLUSION Patients in communities with the lowest ICEIncome values use more inpatient and ED resources after primary TKA. Incorporating ICEIncome into risk-adjusted payment models may help align incentives for equitable care.
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Affiliation(s)
- Shay I Warren
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Nicole S Pham
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Cameron W Foreman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
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Chatad D, Monas A, Rodriguez AN, Roth E, Erez O, Razi AE. Trends and risk factors for readmissions following press-fit total knee arthroplasty for the treatment of end-stage osteoarthritis of the knee: a five-year analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3495-3499. [PMID: 37195308 DOI: 10.1007/s00590-023-03578-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/05/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION The development of new prostheses with improved osseointegration, bone preservation, and reduced cost has renewed interest in uncemented total knee arthroplasty (UCTKA). In the current study, we aimed to: (1) assess demographic data of patients who were and were not readmitted and (2) identify patient-specific risk factors associated with readmission. METHODS A retrospective query from the PearlDiver database was performed from January 1, 2015, to October 31, 2020. International Classification of Disease, Ninth Revision (ICD-9), ICD-10, or Current Procedural Terminology (CPT) coding was used to distinguish cohorts of patients who had osteoarthritis of the knee and underwent UCTKA. Patients readmitted within 90 days were classified as the study population, while those who were not readmitted were classified as control. A linear regression model was utilized to analyze readmission risk factors. RESULTS The query yielded 14,575 patients, with 986 (6.8%) being readmitted. Patient demographics such as age (P < 0.0001), sex (P < 0.009), and comorbidity (P < 0.0001) were associated with annual 90-day readmission. Patient-specific risk factors associated with 90-day readmission following press-fit total knee arthroplasty were: arrhythmia (OR: 1.29, 95% CI: 1.11-1.49, P < 0.0005), coagulopathy (OR: 1.36, 95% CI: 1.13-1.63, P < 0.0007), fluid and electrolyte abnormalities (OR: 1.59, 95% CI: 1.38-1.84, P < 0.0001), iron deficiency anemia (OR: 1.49, 95% CI: 1.27-1.73, P < 0.0001), and obesity (OR: 1.37, 95% CI: 1.18-1.60, P < 0.0001). DISCUSSION This study demonstrates that patients with comorbidities, such as fluid and electrolyte problems, iron deficiency anemia, and obesity, were at an increased risk of readmission after having an uncemented total knee replacement. The risks of readmission following an uncemented total knee arthroplasty can be discussed with patients who have certain comorbidities by arthroplasty surgeons.
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Affiliation(s)
- Derrick Chatad
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
- College of Medicine, State University of New York Downstate, Brooklyn, NY, USA
| | - Arie Monas
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
- College of Medicine, State University of New York Downstate, Brooklyn, NY, USA
| | - Ariel N Rodriguez
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA.
| | - Eric Roth
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Orry Erez
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Afshin E Razi
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
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Kebeh M, Dlott CC, Tung WS, Kurek D, Johnson CB, Wiznia DH. Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Improving Patient Access to Musculoskeletal Care. Orthop Nurs 2023; 42:279-288. [PMID: 37708523 PMCID: PMC10662942 DOI: 10.1097/nor.0000000000000968] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
Preoperative optimization programs for total joint arthroplasty identify and address risk factors to reduce postoperative complications, thereby improving patients' ability to be safe surgical candidates. This article introduces preoperative optimization programs and describes the role of orthopaedic nurse navigators. This foundation will be used to produce an article series with recommendations for optimization of several modifiable biopsychosocial factors. We consulted orthopaedic nurse navigators across the United States and conducted a literature review regarding preoperative optimization to establish the importance of nurse navigation in preoperative optimization. The responsibilities of nurse navigators, cited resources, and structure of preoperative optimization programs varied among institutions. Optimization programs relying on nurse navigators frequently demonstrated improved outcomes. Our discussions and literature review demonstrated the integral role of nurse navigators in preoperative optimization. We will discuss specific risk factors and how nurse navigators can manage them throughout this article series.
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Affiliation(s)
- Martha Kebeh
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Chloe C. Dlott
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Wei Shao Tung
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Donna Kurek
- National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL, USA
- OrthoVirginia, Chesterfield, VA, USA
| | - Charla B. Johnson
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Kunkle BF, Baxter NA, Caughman AM, Barcel JA, Scott DJ, Gross CE. Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis. Foot Ankle Spec 2023; 16:370-376. [PMID: 35583105 DOI: 10.1177/19386400221090358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION While many patients benefit from nonoperative treatment of insertional Achilles tendinopathy (IAT), some elect for surgical debridement and reconstruction. The purpose of this study is to determine the relationship of patient demographic characteristics, comorbidity profiles, and radiological parameters with failure of conservative management of IAT. METHODS A retrospective chart review was performed to identify patients who received either surgical or nonsurgical treatment of IAT at an academic institution from September 2015 to June 2019 (N = 226). Demographic and comorbidity data, and the presence and magnitude of relevant radiological parameters were collected and compared between the surgically (n = 48) and nonsurgically (n = 178) treated groups. RESULTS No significant differences could be detected between groups regarding demographic factors or previous procedures. The surgery group was significantly more likely to have evidence of Haglund's deformity on clinical exam (83% vs 69%, P = .005), lower SF-12 physical scores (25.5 vs 35.5, P < .001), higher VAS pain scores (6.3 vs 5.3, P = .033), any mental illness (33% vs 20%, P = .044), and depression (27% vs 12%, P = .012). DISCUSSION Patients who received surgery for IAT were significantly more likely to have evidence of Haglund's deformity on clinical exam, depression, higher VAS pain scores, and lower SF-12 physical scores. Both patients and surgeons should be aware of the higher rates of failure of conservative treatment in these patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Bryce F Kunkle
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Nicholas A Baxter
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Alexander M Caughman
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - John A Barcel
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel J Scott
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
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Churchill JL, Paez CJ, Entezari V, Ricchetti ET, Ho JC. Understanding Medical Optimization for Patients Undergoing Shoulder Arthroplasty. Orthop Clin North Am 2023; 54:309-318. [PMID: 37271559 DOI: 10.1016/j.ocl.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Many surgeons seek to optimize their patients' comorbid conditions preoperatively to reduce postoperative complications. To effectively optimize patients before total shoulder arthroplasty, the surgeon should be familiar with recognizing and treating common medical comorbidities found in an orthopedic patient including anemia, diabetes, malnutrition, cardiovascular conditions, and history of deep venous thrombosis. Screening for depression or other mental illness should also be conducted preoperatively and managed accordingly before surgery. Preoperative opioid use and smoking have significant effects on postoperative outcomes and should be addressed before surgery.
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Affiliation(s)
- Jessica L Churchill
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Conner J Paez
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Vahid Entezari
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Eric T Ricchetti
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jason C Ho
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, A40, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Kamalapathy PN, Wang KY, Puvanesarajah V, Raad M, Hassanzadeh H. Presence and Severity of Mental Illness Is Associated With Increased Risk of Postoperative Emergency Visits, Readmission, and Reoperation Following Outpatient ACDF: A National Database Analysis. Global Spine J 2023; 13:1267-1272. [PMID: 34212775 PMCID: PMC10416597 DOI: 10.1177/21925682211026913] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose was to compare rates of postoperative ED visits, readmission, and reoperation between patients with and without preexisting mental illness undergoing outpatient anterior cervical discectomy and fusion (ACDF). METHODS A retrospective review of the Mariner Database was conducted on patients who underwent ACDF between 2010 and 2017. Exclusion criteria included same day revision surgery and patients with a history of spine infection, trauma, or neoplasm. Patients were grouped into 3 categories: those with existing history of anxiety and/or depression, those with severe mental illness, and those without any history of mental illness. Severe mental illness was defined as a combination of diagnosis including schizophrenia, bipolar disorder, and/or psychotic disorder. Outcome measures were analyzed by comparing groups using multivariate logistic regression. Significance was set at P < 0.05. RESULTS Patients with anxiety/depression and patients with severe mental illness both had significantly increased risk of ED visits and readmission at 30-day and 90-day intervals. Compared to patients without mental illness, patients with severe mental illness (OR 1.93, P < 0.001) had significantly increased rates of reoperation at 90-days and 1-years postoperatively. Patients with anxiety/depression did not have increased rates of reoperation relative to patients without anxiety/depression at any time interval (P > 0.05). CONCLUSION Anxiety/depression as well as more severe psychiatric disease such as Schizophrenia and Bipolar disorder were significantly associated with increased healthcare utilization following outpatient ACDF. Patients with preexisting mental illness undergoing outpatient ACDF should be carefully evaluated preoperatively and closely followed postoperatively to reduce risk of adverse events.
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Affiliation(s)
| | - Kevin Y. Wang
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
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Hecht CJ, Burkhart RJ, Karimi AH, Acuña AJ, Kamath AF. What is the Association Between Clinically Diagnosed Psychiatric Illness and Total Joint Arthroplasty? A Systematic Review Evaluating Outcomes, Healthcare Use, and Patient-reported Outcome Measures. Clin Orthop Relat Res 2023; 481:947-964. [PMID: 36730492 PMCID: PMC10097587 DOI: 10.1097/corr.0000000000002481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/12/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Studies evaluating the effects of a psychiatric illness on orthopaedic surgical outcomes have yielded mixed results. Because awareness of patient comorbid mental health disorders has become increasingly important to tailor treatment plans, the aim of our systematic review was to present the findings of all studies reporting on the association between clinically diagnosed psychiatric illnesses and total joint arthroplasty (TJA) outcomes and evaluate the quality of evidence to provide a comprehensive summary. QUESTION/PURPOSE Is there a consistently reported association between comorbid psychiatric illness and (1) complication risk, (2) readmission rates, (3) healthcare use and discharge disposition, and (4) patient-reported outcome measures (PROMs) after TJA? METHODS The PubMed, EBSCO host, Medline, and Google Scholar electronic databases were searched on April 9, 2022, to identify all studies that evaluated outcomes after TJA in patients with a comorbid clinically diagnosed mental health disorder between January 1, 2000, and April 1, 2022. Studies were included if the full-text article was available in English, reported on primary TJA outcomes in patients with clinically diagnosed mental health disorders, included patients undergoing TJA without a psychiatric illness for comparison, and had a minimum follow-up time of 30 days for evaluating readmission rates, 90 days for other perioperative outcomes such as length of stay and complications, and 1-year minimum follow-up if assessing PROMs. Studies that used a mental health screening examination instead of clinical diagnoses were excluded to isolate for verified psychiatric illnesses. Additionally, systematic reviews, case reports, duplicate studies between the databases, and gray literature were excluded. Twenty-one studies were included in our final analysis comprising 31,023,713 patients with a mean age range of 57 to 69 years. Mental health diagnoses included depression, anxiety, bipolar disorder, schizophrenia, major personality disorder, and psychosis as well as concomitant mental disorders. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 19.5 ± 0.91 of 24, with higher scores representing better study quality. All the articles included were retrospective, comparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed, and results are instead presented descriptively. RESULTS Patients with schizophrenia were consistently reported to have higher odds of medical and surgical complications than patients without psychiatric illness, particularly anemia and respiratory complications. Among studies with the largest sample sizes, patients with depression alone or depression and anxiety had slightly higher odds of complications. Most studies identified higher odds of readmission among patients with depression, schizophrenia, and severe mental illness after TJA. However, for anxiety, there was no difference in readmission rates compared with patients without psychiatric illness. Slightly higher odds of emergency department visits were reported for patients with depression, anxiety, concomitant depression and anxiety, and severe mental illness across studies. When evaluating healthcare use, articles with the largest sample sizes reporting on depression and length of stay or discharge disposition found modestly longer length of stay and greater odds of nonhome discharge among patients with depression. Although several studies reported anxiety was associated with slightly increased total costs of hospitalization, the most robust studies reported no difference or slightly shorter average length of stay. However, the included studies only reported partial economic analyses of cost, leading to relatively superficial evidence. Patients with schizophrenia had a slightly longer length of stay and modestly lower odds of home discharge and cost. Likewise, patients with concomitant depression and anxiety had a slightly longer average length of stay, according to the two articles reporting on more than 1000 patients. Lastly, PROM scores were worse in patients with depression at a minimum follow-up of 1 year after TJA. For anxiety, there was no difference in improvement compared with patients without mental illness. CONCLUSION Our systematic review found that individuals with psychiatric illness had an increased risk of postoperative complications, increased length of stay, higher costs, less frequent home discharge, and worse PROM scores after TJA. These findings encourage inclusion of comorbid psychiatric illness when risk-stratifying patients. Attention should focus on perioperative interventions to minimize the risk of thromboembolic events, anemia, bleeding, and respiratory complications as well as adequate pain management with drugs that do not exacerbate the likelihood of these adverse events to minimize emergency department visits and readmissions. Future studies are needed to compare patients with concomitant psychiatric illnesses such as depression and anxiety with patients with either diagnosis in isolation, instead of only comparing patients with concomitant diagnoses with patients without any psychiatric illnesses. Similarly, the results of targeted interventions such as cognitive behavioral therapy are needed to understand how orthopaedic surgeons might improve the quality of care for patients with a comorbid psychiatric illness.
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Affiliation(s)
- Christian J. Hecht
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert J. Burkhart
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Amir H. Karimi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alexander J. Acuña
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Atul F. Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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14
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Sumbal R, Murtaza M, Sumbal A, Farooq A, Ali Baig MM, Qadar LT. Relationship Between Mental Health Disorders and Readmissions Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2023; 38:188-193.e1. [PMID: 35987494 DOI: 10.1016/j.arth.2022.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 08/07/2022] [Accepted: 08/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is limited evidence exploring the relationship between mental health disorders and the readmissions following total joint arthroplasty (TJA). Therefore, we conducted a meta-analysis to evaluate the relationship between mental health disorders and the risk of readmission following TJA. METHODS We searched PubMed, Cochrane, and Google Scholar from their inception till April 19, 2022. Studies exploring the association of mental health disorders and readmission risk following TJA were selected. The outcomes were divided into 30-day readmission, 90-day readmission, and readmission after 90 days. We also performed subgroup analyses based on the type of arthroplasty: total hip arthroplasty (THA) and total knee arthroplasty (TKA). A total of 12 studies were selected, of which 11 were included in quantitative analysis. A total of 1,345,893 patients were evaluated, of which 73,953 patients suffered from mental health disorders. RESULTS The risk of 30-day readmission (odds ratio = 1.43, 95% CI 1.14-1.80, P = .002, I2 = 87%) and 90-day readmission (OR = 1.35, 95% CI 1.22-1.49, P < .00001, I2 = 89%) was significantly associated with mental health disorders. On subgroup analyses, 30-day readmission was significantly associated with THA (OR = 1.29, 95% CI 1.04-1.60, P = .02), but not with TKA (OR = 1.44, 95% CI 0.51-4.06, P = .50). Similarly, 90-day readmission was significantly associated with both THA (OR = 1.21, 95% CI 1.14-1.29, P < .00001) and TKA (OR = 1.33, 95% CI 1.17-1.51, P < .0001). CONCLUSION Mental health disorders are significantly associated with increased 30-day and 90-day readmissions. Increasing awareness regarding mental health disorders and readmission in arthroplasty will help in efficient preoperative risk stratification and better postoperative management in these patients.
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Affiliation(s)
- Ramish Sumbal
- Dow medical college, Dow University of Health Sciences, Karachi, Pakistan
| | - Minha Murtaza
- Dow medical college, Dow University of Health Sciences, Karachi, Pakistan
| | - Anusha Sumbal
- Dow medical college, Dow University of Health Sciences, Karachi, Pakistan
| | - Aamna Farooq
- Dow medical college, Dow University of Health Sciences, Karachi, Pakistan
| | - Mirza M Ali Baig
- Dow medical college, Dow University of Health Sciences, Karachi, Pakistan
| | - Laila Tul Qadar
- Dow medical college, Dow University of Health Sciences, Karachi, Pakistan
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15
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Shaw DB, Carreira DS. The Impacts of Anxiety and Depression on Outcomes in Foot and Ankle Surgery. Foot Ankle Int 2022; 43:1606-1613. [PMID: 36367127 DOI: 10.1177/10711007221132277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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Sinclair ST, Klika AK, Jin Y, Higuera CA, Piuzzi NS. The Impact of Surgeon Variability on Patient-Reported Outcome Measures, Length of Stay, Discharge Disposition, and 90-Day Readmission in TKA. J Bone Joint Surg Am 2022; 104:2016-2025. [PMID: 36047698 DOI: 10.2106/jbjs.21.01339] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Studies involving total knee arthroplasty (TKA) have focused on patient-related factors as drivers of outcomes. Although some studies have investigated surgeon and/or surgery-level factors (i.e., approach, volume), the measure of variance in postoperative outcomes across surgeons following TKA has not been determined. The aim of the current study was to evaluate the relationship between the surgeon and 1-year patient-reported outcome measures, the length of stay, the discharge disposition, and 90-day readmission after TKA, as well as the differences in these variables among surgeons. METHODS Data were prospectively collected for 5,429 patients who underwent TKA at a large health-care system with 36 surgeons between 2016 and 2018. Likelihood ratio tests were performed to investigate the relationship between surgeon and the 1-year Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain subscale, KOOS-Physical Function Shortform (KOOS-PS), KOOS for Joint Replacement (KOOS-JR), patient acceptable symptom state (PASS), length of stay, discharge disposition, and 90-day readmission. The minimal clinically important difference (MCID) was used to assess meaningful outcomes. Variable importance was determined by the Akaike information criterion (AIC) increase, using ordinal and binary-response mixed-effect models. RESULTS There was a significant association between surgeon and KOOS-Pain (p < 0.001), KOOS-PS (p = 0.001), KOOS-JR (p < 0.001), PASS (p = 0.024), length of stay (p < 0.001), discharge disposition (p < 0.001), and 90-day readmission (p < 0.001). When modeling 1-year KOOS-Pain (AIC increase, 15.6), KOOS-PS (AIC increase, 6.8), KOOS-JR (AIC increase, 13.5), PASS (AIC increase, 1.9), length of stay, and discharge disposition, the surgeon variable contributed more to the 1-year outcome than some patient-level factors (e.g., body mass index, Charlson Comorbidity Index). The difference between the highest and lowest median probabilities of attaining the same value for the KOOS-Pain (11.2%), KOOS-PS (9.4%), KOOS-JR (11.8%), PASS (5.9%), length of stay (46.6%), discharge disposition (22.8%), and readmission (13.1%) indicated surgeon-level variability. CONCLUSIONS Surgeon-related factors may be stronger contributors to the 1-year patient-reported outcome measures and length of stay than patient characteristics emphasized in the literature. Current findings have suggested variability in patient-reported outcome measures, length of stay, discharge location, and 90-day readmission among surgeons. Surgeon variability should be considered when model-fitting in the setting of TKA. LEVEL OF EVIDENCE Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- SaTia T Sinclair
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida.,Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Yuxuan Jin
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio
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17
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Ackermann RT, Liss DT, French DD, Cooper AJ, Aikman C, Schaeffer C. Randomized Trial Evaluating Health System Expenditures with Transitional Care Services for Adults with No Usual Source of Care at Discharge. J Gen Intern Med 2022; 37:3832-3838. [PMID: 35266127 PMCID: PMC9640508 DOI: 10.1007/s11606-022-07473-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/22/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Multidisciplinary transitional care services reduce readmissions for high-risk patients, but it is unclear if health system costs to offer these intensive services are offset by avoidance of higher downstream expenditures. OBJECTIVE To evaluate net costs for a health system offering transitional care services DESIGN: One-year pragmatic, randomized trial PARTICIPANTS: Adults aged ≥ 18 without a usual source of follow-up care at the time of hospital discharge were enrolled through a high-volume, urban academic medical center in Chicago, IL, USA, from September 2015 through February 2016. INTERVENTIONS Eligible patients were silently randomized before discharge by an automated electronic health record algorithm allocating them in a 1:3 ratio to receive routine coordination of post-discharge care (RC) versus being offered intensive, multidisciplinary transitional care (TC) services. MAIN MEASUREMENTS Health system costs were collected from facility administrative systems and transformed to standardized costs using Medicare reference files. Multivariable generalized linear models estimated proportional differences in net costs over one year. KEY RESULTS Study patients (489 TC; 164 RC) had a mean age of 44 years; 34% were uninsured, 55% had public insurance, and 49% self-identified as Black or Latinx. Over 90 days, cost differences between groups were not statistically significant. Over 180 days, the TC group had 41% lower ED/observation costs (adjusted cost ratio [aCR], 0.59; 95% CI, 0.36-0.97), 50% lower inpatient costs (aCR, 0.50; 95% CI, 0.27-0.95), and 41% lower total healthcare costs (aCR, 0.59; 95% CI, 0.36-0.99) than the RC group. Over 365 days, total cost differences remained of similar magnitude but no longer were statistically significant. CONCLUSIONS Offering TC services for vulnerable adults at discharge reduced net health system expenditures over 180 days. The promising economic case for multidisciplinary transitional care interventions warrants further research. TRIAL REGISTRATION National Clinical Trials Registry (NCT03066492).
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Affiliation(s)
- Ronald T Ackermann
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA.
| | - David T Liss
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
| | - Dustin D French
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Veterans Affairs Health Services Research and Development Service, Chicago, IL, USA
| | - Andrew J Cooper
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
| | - Cassandra Aikman
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
| | - Christine Schaeffer
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
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18
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Rogers NB, Grits D, Emara AK, Higuera CA, Molloy RM, Klika AK, Piuzzi NS. Preoperative Veterans Rand-12 Mental Composite Score of < 40 Leads to Increased Healthcare Utilization and Diminished Improvement After Primary Knee Arthroplasty. J Arthroplasty 2022; 37:2178-2185. [PMID: 35598758 DOI: 10.1016/j.arth.2022.05.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/04/2022] [Accepted: 05/16/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Adverse outcomes after total knee arthroplasty (TKA) have been associated with preoperative psychological disorders and poor mental health. We aimed to investigate and quantify the association between preoperative mental health and 1) postoperative 90-day health care utilization; and 2) 1-year patient-reported outcomes after primary TKA. METHODS Retrospective review of prospectively collected data of patients who underwent primary elective TKA (n = 7,476) was performed. Preoperative mental health was evaluated using Veterans Rand-12 Mental Composite Scores (VR-12 MCS). Outcomes included prolonged length of stay (>2-days), nonhome discharge, 90-day readmissions, emergency department visits, and reoperation. Improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) and Patient Acceptable Symptom State (PASS) achievement were evaluated at 1-year. Multivariable regression was implemented to explore associations between preoperative VR-12 MCS and outcomes of interest. RESULTS A total of 5,402 (72.3%) completed 1-year follow-up. Lower preoperative VR-12 MCS was associated with higher odds of prolonged length of stay (MCS 20-39: odds ratio (OR): 1.46;P < .001), and nonhome discharge disposition (MCS 20-39: OR: 1.92;P < .001), but not 90-day readmission or reoperation (MCS20-39; P = .12 and P = .64). At 1-year, patients with a lower MCS were less likely to attain a substantial clinical benefit in KOOS-pain (MCS 0-19; OR: 0.25; P < .001) and less likely to achieve PASS (MCS20-39; OR: 0.74; P = .002). Patients with an MCS >60 were more likely to be discharged home (OR: 1.42; P = .008), achieve substantial clinical benefit in their KOOS-JR (OR: 1.16; P = .027),-Pain (OR: 1.220; P = .007) and PASS at 1-year (OR: 1.28; P = .008). CONCLUSIONS Lower VR-12 MCS is associated with increased postoperative health care utilization and worse patient-reported outcome measures at 1-year post-TKA. These findings suggest that a VR-12 MCS ≤40 could be used to designate increased risk, guide the preoperative discussion and potential interventions.
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Affiliation(s)
- Nathan B Rogers
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Daniel Grits
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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19
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Secrist E, Wally MK, Yu Z, Castro M, Seymour RB, Hsu JR. Depression Screening and Behavioral Health Integration in Musculoskeletal Trauma Care. J Orthop Trauma 2022; 36:e362-e368. [PMID: 35981227 DOI: 10.1097/bot.0000000000002361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To report our experiences in implementing a behavioral health integration pathway, including a validated depression screening and referral to care. DESIGN Retrospective case series. SETTING Single surgeon's musculoskeletal trauma outpatient practice during calendar year 2019. PATIENTS All patients presenting to the practice during 2019 were included (n = 573). INTERVENTION We piloted the usage of Patient Health Questionnaire (PHQ)-2 and PHQ-9 screening. An evidence-based, real-time treatment protocol embedded in the electronic health record was triggered when a patient screened positive for depression including an automated behavioral health integration pathway. MAIN OUTCOME MEASUREMENTS The percentage of patients screened, the results of the PHQ screening, and the number of patients referred and enrolled in behavioral health programs were collected. RESULTS Of the 573 patients, 476 (83%) received the PHQ-2 screening, 80 (14%) had a current screening on file (within 1 year), and 17 (3.0%) were not screened. One hundred seventy-two patients (36%) had a PHQ-2 score of 2 or greater and completed the PHQ-9; of them, 60 (35% of patients screened with full PHQ-9, 13% of patients screened) screened positive for symptoms of moderate depression (PHQ-9 score ≥10), and 19 (4.0%) reported passive suicidal ideation (PHQ-9 item 9). Fifty of these patients were referred to behavioral health through the pathway, and 8 patients enrolled in the program. Ten patients were not referred because of a technical error that was quickly resolved. Patients reporting suicidal ideation were managed with psychiatric crisis resources including immediate virtual consult in the examination room. CONCLUSIONS This case series demonstrates the feasibility of screening patients for depressive symptoms and making necessary referrals to behavioral health in outpatient musculoskeletal trauma care. We identified 50 patients with depression and appropriately triaged them for further care in our community.
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Affiliation(s)
- Eric Secrist
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Manuel Castro
- Department of Psychiatry, Atrium Health, Charlotte, NC
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
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20
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Klemt C, Tirumala V, Habibi Y, Buddhiraju A, Chen TLW, Kwon YM. The utilization of artificial neural networks for the prediction of 90-day unplanned readmissions following total knee arthroplasty. Arch Orthop Trauma Surg 2022; 143:3279-3289. [PMID: 35933638 DOI: 10.1007/s00402-022-04566-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/19/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND A reliable predictive tool to predict unplanned readmissions has the potential to lower readmission rates through targeted pre-operative counseling and intervention with respect to modifiable risk factors. This study aimed to develop and internally validate machine learning models for the prediction of 90-day unplanned readmissions following total knee arthroplasty. METHODS A total of 10,021 consecutive patients underwent total knee arthroplasty. Patient charts were manually reviewed to identify patient demographics and surgical variables that may be associated with 90-day unplanned hospital readmissions. Four machine learning algorithms (artificial neural networks, support vector machine, k-nearest neighbor, and elastic-net penalized logistic regression) were developed to predict 90-day unplanned readmissions following total knee arthroplasty and these models were evaluated using ROC AUC statistics as well as calibration and decision curve analysis. RESULTS Within the study cohort, 644 patients (6.4%) were readmitted within 90 days. The factors most significantly associated with 90-day unplanned hospital readmissions included drug abuse, surgical operative time, and American Society of Anaesthesiologist Physical Status (ASA) score. The machine learning models all achieved excellent performance across discrimination (AUC > 0.82), calibration, and decision curve analysis. CONCLUSION This study developed four machine learning models for the prediction of 90-day unplanned hospital readmissions in patients following total knee arthroplasty. The strongest predictors for unplanned hospital readmissions were drug abuse, surgical operative time, and ASA score. The study findings show excellent model performance across all four models, highlighting the potential of these models for the identification of high-risk patients prior to surgery for whom coordinated care efforts may decrease the risk of subsequent hospital readmission. LEVEL OF EVIDENCE Level III, case-control retrospective analysis.
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Affiliation(s)
- Christian Klemt
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Venkatsaiakhil Tirumala
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Yasamin Habibi
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Anirudh Buddhiraju
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Tony Lin-Wei Chen
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Young-Min Kwon
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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21
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Wilson JM, Schwartz AM, Farley KX, Bariteau JT. Preoperative Depression Influences Outcomes Following Total Ankle Arthroplasty. Foot Ankle Spec 2022; 15:321-329. [PMID: 32865018 DOI: 10.1177/1938640020951657] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Total ankle arthroplasty (TAA) is increasing in incidence. While preoperative depression is known to affect outcomes following other procedures, its effect on outcomes following TAA are unknown. Therefore, the purpose of this study was to investigate this relationship. METHODS This is a retrospective cohort study using the Nationwide Readmission Database (NRD). All patients undergoing TAA were included. Two cohorts (those with and without preoperative depression) were created. Logistic regression was then performed to assess the contribution of a preoperative diagnosis of depression on rates of 90-day complications, while controlling for patient demographic and comorbid data. RESULTS Overall, 8047 patients were included, of whom, 11.4% (918) were depressed. Compared to patients without depression, patients with depression had increased odds of the following: nonhome discharge (OR 1.61, 95% CI 1.31-1.98), extended length of stay (>2 days; OR 1.34, 95% CI 1.15-1.57), prosthetic complication (OR 1.39, 95% CI 1.10-1.74), wound complication (OR 1.59, 95% CI 1.11-2.29), prosthetic joint infection (OR 1.82, 95% CI 1.06-3.15), superficial surgical site infection (OR 1.62, 95% CI 1.02-2.58), and medical complication (OR 1.32, 95% CI 1.03-1.68). DISCUSSION Depression in patients undergoing TAA is common and is associated with increased health care utilization and complications following surgery. The modifiability of depression should be investigated with future studies. LEVELS OF EVIDENCE Prognostic, Level III: Comparative study.
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Affiliation(s)
- Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Andrew M Schwartz
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Kevin X Farley
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Jason T Bariteau
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
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22
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Passano B, Oakley CT, Singh V, Lygrisse KA, Schwarzkopf R, Lajam CM. Documented and Undocumented Psychiatric Conditions Affect the Length of Stay and Discharge Disposition Following Total Hip Arthroplasty. J Arthroplasty 2022; 37:727-733. [PMID: 34896552 DOI: 10.1016/j.arth.2021.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/21/2021] [Accepted: 11/30/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite increased efforts toward patient optimization, some patients have undocumented conditions that can affect costs and quality metrics for institutions and physicians. This study evaluates the effect of documented and undocumented psychiatric conditions on length of stay (LOS) and discharge disposition following total hip arthroplasty (THA). METHODS A retrospective review of all primary THAs from 2015 to 2020 at a high-volume academic orthopedic specialty hospital was conducted. Patients were separated into 3 cohorts: patients with a documented psychiatric diagnosis (+Dx), patients without a documented psychiatric diagnosis but with an actively prescribed psychiatric medication (-Dx), and patients without a psychiatric diagnosis or medication (control). Patient demographics, LOS, and discharge disposition were assessed. RESULTS A total of 5309 patients were included; 3048 patients had no recorded psychiatric medications (control); 2261 patients took at least 1 psychiatric medication, of which 1513 (65.9%) and 748 (34.1%) patients were put in the -Dx and +Dx cohorts, respectively. American Society of Anesthesiologists class differed between groups (P < .001). The -Dx and +Dx groups had increased LOS (3.15 ± 2.37 [75.6 ± 56.9] and 3.12 ± 2.27 [74.9 ± 54.5] vs 2.42 ± 1.70 [57.6 ± 40.8] days (hours), P < .001) and were more likely to be discharged to a secondary facility (23.0% and 21.7% vs 13.8%, P < .001) than the control group. Outcomes did not significantly differ between the -Dx and +Dx cohorts. CONCLUSION Most THA patients' psychiatric diagnoses were not documented. The presence of psychiatric medications was associated with longer LOS and a greater likelihood of discharge to secondary facilities. This has implications for both cost and quality metrics. Review of medications can help identify and optimize these patients before surgery. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Brandon Passano
- Department of Orthopedic Surgery, NYU Langone Hospital - Long Island, Mineola, NY
| | | | - Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | | | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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23
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Lazarides AL, Flamant EM, Cullen MM, Ferlauto HR, Cochrane N, Gao J, Jung SH, Visgauss JD, Brigman BE, Eward WC. Investigating readmission rates for patients undergoing oncologic resection and endoprosthetic reconstruction for primary sarcomas and tumors involving bone. J Surg Oncol 2022; 126:356-364. [PMID: 35319106 DOI: 10.1002/jso.26864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 02/21/2022] [Accepted: 03/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Little is known about the drivers of readmission in patients undergoing Orthopaedic oncologic resection. The goal of this study was to identify factors independently associated with 90-day readmission for patients undergoing oncologic resection and subsequent prosthetic reconstruction for primary tumors involving bone. METHODS This was a retrospective comparative cohort study of patients treated from 2008 to 2019 who underwent endoprosthetic reconstruction for a primary bone tumor or soft tissue tumor involving bone, as well as those who underwent a revision endoprosthetic reconstruction if the primary endoprosthetic reconstruction was performed for an oncologic resection. The primary outcome measure was unplanned 90-day readmission. RESULTS A total of 149 patients were identified who underwent 191 surgeries were for a primary bone or soft tissue tumor. The 90-day readmission rate was 28.3%. Female gender, depression, higher tumor grade, vascular reconstruction, longer procedure duration, longer length of stay (LOS), multiple surgeries during an admission and disposition to a Skilled Nursing Facility were associated with readmission (p < 0.05). In a multivariate analysis, female sex, higher tumor grade and longer procedure duration were independently associated with risk of readmission (p < 0.05). CONCLUSIONS Readmission rates are high following endoprosthetic reconstruction for Orthopaedic oncologic resections. Further work is necessary to help minimize unplanned readmissions.
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Affiliation(s)
- Alexander L Lazarides
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Etienne M Flamant
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Mark M Cullen
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Harrison R Ferlauto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Niall Cochrane
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Junheng Gao
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Sin-Ho Jung
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Julia D Visgauss
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Brian E Brigman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - William C Eward
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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24
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Bourget-Murray J, Parkar A, Railton P, Evaniew N, Powell J. Effects of Perioperative Selective Serotonin Reuptake Inhibitor Use in Primary Total Hip and Knee Arthroplasty. J Arthroplasty 2022; 37:454-459. [PMID: 34775004 DOI: 10.1016/j.arth.2021.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/22/2021] [Accepted: 11/06/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The aim of this study is to compare functional outcomes and perioperative complications between patients on a selective serotonin reuptake inhibitor (SSRI) and those who are not on an SSRI preoperatively at the time of total joint arthroplasty. METHODS A retrospective study was performed on 28,386 patients who received a primary total hip (THA) or knee (TKA) arthroplasty. Patients were compared based on SSRI utilization. We measured patient-reported function and health-related quality of life using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the EuroQol-5 Dimensions (EQ-5D-5L) instruments. Chi-squared test was used to compare categorical variables and t-test was used to compare the continuous variables of 2 study groups. RESULTS Patients on SSRIs have lower preoperative baseline WOMAC and EQ-5D-5L scores than those not using SSRI (P < .001). Patient-reported outcomes improved significantly following surgery, but functional outcome scores remained inferior in patients using SSRI. After adjusting for baseline variables, SSRI use in TKA predicted lower EQ-5D-5L scores than non-SSRI users (P = .036) while the WOMAC scores were not different (P = .118). For the THA cohort, SSRI use predicted lower EQ-5D-5L (P = .001) and WOMAC scores than non-SSRI users (P = .008). SSRI use was associated with increased transfusion rate, length of stay, readmission rate, and medical events. About 11.3% of TKA and 13.3% of THA patients stopped using SSRI at 12 months after arthroplasty. CONCLUSION Patients using an SSRI show improvement comparable to patients not on an SSRI, but their 12-month functional scores continue to be inferior. SSRI utilization was associated with increased adverse events including needing a blood transfusion.
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Affiliation(s)
- Jonathan Bourget-Murray
- Division of Orthopaedic Surgery, Department of Surgery, Alberta Bone and Joint Health Institute, Calgary, Alberta, Canada
| | - Asif Parkar
- Division of Orthopaedic Surgery, Department of Surgery, Alberta Bone and Joint Health Institute, Calgary, Alberta, Canada
| | - Pam Railton
- Division of Orthopaedic Surgery, Department of Surgery, Alberta Bone and Joint Health Institute, Calgary, Alberta, Canada
| | - Nathan Evaniew
- Division of Orthopaedic Surgery, Department of Surgery, Alberta Bone and Joint Health Institute, Calgary, Alberta, Canada
| | - James Powell
- Division of Orthopaedic Surgery, Department of Surgery, Alberta Bone and Joint Health Institute, Calgary, Alberta, Canada
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25
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Hegde V, Bracey DN, Johnson RM, Dennis DA, Jennings JM. Increased Prevalence of Depressive Symptoms in Patients Undergoing Revision for Periprosthetic Joint Infection. Arthroplast Today 2022; 13:69-75. [PMID: 34977309 PMCID: PMC8685908 DOI: 10.1016/j.artd.2021.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/16/2021] [Accepted: 09/20/2021] [Indexed: 11/19/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty. Patients undergoing revision for PJI may experience psychological distress and symptoms of depression, both of which are linked to poor postoperative outcomes. We, therefore, aim to identify the prevalence of depression and depressive symptoms in patients before treatment for PJI and their link to functional outcomes. Methods Patients undergoing either debridement with implant retention (DAIR) or 2-stage exchange for PJI with minimum 1-year follow-up were retrospectively reviewed. The 2-stage (n = 37) and single-stage (n = 39) patients that met inclusion criteria were matched based off age (±5 years), gender, and body mass index (±5) to patients undergoing aseptic revisions. Outcomes evaluated included a preoperative diagnosis of clinical depression and preoperative and postoperative Veterans RAND 12 Item Health Survey mental component score and physical component score. Results Compared to matched controls, the prevalence of depressive symptoms was significantly greater in patients undergoing 2-stage exchange preoperatively (40.5% vs 10.8%, P < .01) but not postoperatively (21.6% vs 10.8%, P = .20). Patients undergoing DAIR with either preoperative depressive symptoms (31.3 vs 40.9, P = .05) or a preoperative diagnosis of depression (27.7 vs 43.1, P < .01) had significantly lower physical component scores postoperatively. Conclusions Patients undergoing 2-stage exchange for PJI have a four times higher prevalence of preoperative depressive symptoms than patients undergoing aseptic revision. Patients undergoing DAIR with depression or preoperative depressive symptoms have lower functional scores postoperatively. Orthopedic surgeon screening of PJI patients with referral for treatment of depression may help improve outcomes postoperatively.
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Affiliation(s)
- Vishal Hegde
- Colorado Joint Replacement, Denver, CO, USA
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Daniel N. Bracey
- Colorado Joint Replacement, Denver, CO, USA
- Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA
| | | | - Douglas A. Dennis
- Colorado Joint Replacement, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
- Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO, USA
- Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
- Corresponding author. 2535 S Downing St. Suite 100, Denver, CO 80210. Tel.: 303-260-2940.
| | - Jason M. Jennings
- Colorado Joint Replacement, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
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26
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Qin HC, Luo ZW, Chou HY, Zhu YL. New-onset depression after hip fracture surgery among older patients: Effects on associated clinical outcomes and what can we do? World J Psychiatry 2021; 11:1129-1146. [PMID: 34888179 PMCID: PMC8613761 DOI: 10.5498/wjp.v11.i11.1129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/25/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hip fracture in the elderly is a worldwide medical problem. New-onset depression after hip fracture has also received attention because of its increasing incidence and negative impact on recovery.
AIM To provide a synthesis of the literature addressing two very important questions arising from postoperative hip fracture depression (PHFD) research: the risk factors and associated clinical outcomes of PHFD, and the optimal options for intervention in PHFD.
METHODS We searched the PubMed, Web of Science, EMBASE, and PsycINFO databases for English papers published from 2000 to 2021.
RESULTS Our results showed that PHFD may result in poor clinical outcomes, such as poor physical function and more medical support. In addition, the risk factors for PHFD were summarized, which made it possible to assess patients preoperatively. Moreover, our work preliminarily suggested that comprehensive care may be the optimal treatment option for PHFDs, while interdisciplinary intervention can also be clinically useful.
CONCLUSION We suggest that clinicians should assess risk factors for PHFDs preoperatively, and future research should further validate current treatment methods in more countries and regions and explore more advanced solutions.
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Affiliation(s)
- Hao-Cheng Qin
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Zhi-Wen Luo
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Heng-Yi Chou
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yu-Lian Zhu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
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27
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Kim H, Kim CH. Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2021; 36:3807-3813. [PMID: 34244031 DOI: 10.1016/j.arth.2021.06.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 05/29/2021] [Accepted: 06/17/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To date, no meta-analysis of the relationship between hospital readmission after total joint arthroplasty (TJA) and preoperative depression has been conducted. Hence, this systematic review and meta-analysis aimed to evaluate the association of preoperative depression with the readmission rate following TJA. METHODS We systematically searched MEDLINE, EMBASE, and Cochrane Library for studies published before March 28, 2021, which compared readmission rates in patients with or without preoperative depression who underwent TJA. The primary outcome was the relationship between preoperative depression and 30-day and 90-day readmission rates after TJA. We also performed surgery type subgroup analyses for total hip arthroplasty, total knee arthroplasty (TKA), total shoulder arthroplasty, and total ankle arthroplasty. RESULTS We included 9 studies with 395,815 TJA cases, of which 49,402 were diagnosed with preoperative depression and 346,413 were not. In pooled TJA analysis, the 30-day and 90-day readmission rates were significantly higher in the depression group than in the no-depression group (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.26-2.73, P = .002 and OR 1.27, 95% CI 1.14-1.43,; P < .001, respectively). In the subgroup analyses, the 90-day readmission rate was higher in the depression group than in the no-depression group after TKA (OR 1.28, 95% CI 1.15-1.42, P < .001). There were no differences in other surgery types. CONCLUSION Based on available evidence, preoperative depression increases the readmission rate after TJA, particularly TKA. As depression is a modifiable risk factor, screening for depression and referring patients for proper psychiatric management are important. LEVEL OF EVIDENCE Level III, meta-analysis.
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Affiliation(s)
- Harin Kim
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chul-Ho Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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28
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Knapp P, Layson JT, Mohammad W, Pizzimenti N, Markel DC. The Effects of Depression and Anxiety on 90-day Readmission Rates After Total Hip and Knee Arthroplasty. Arthroplast Today 2021; 10:175-179. [PMID: 34458530 PMCID: PMC8379358 DOI: 10.1016/j.artd.2021.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/05/2021] [Accepted: 06/16/2021] [Indexed: 11/28/2022] Open
Abstract
Background Patients undergoing total joint arthroplasty have higher rates of anxiety, depression or anxiety and depression than the general population and higher costs of care, which lead to higher levels of postoperative dissatisfaction and readmission rates. We evaluated the readmission rates of patients undergoing total hip or knee arthroplasty with diagnoses of anxiety, depression, or both. Methods Our hospital's prospectively collected data from Michigan's statewide total joint database were reviewed from 2013 to 2018. Rates of anxiety, depression or anxiety and depression were determined based on preoperative anxiolytic or antidepressant medications using National Drug Codes. Results A total of 4107 cases were included. Of which 4.28% had a readmission within the 90-day global period, and 12% had a history of depression or anxiety or both. For the entire cohort, those on anxiolytic medication were 153% more likely to be readmitted than those not on medication (P = .017). When comparing total hip arthroplasty (THA) or total knee arthroplasty (TKA), patients taking anxiolytic medication and undergoing TKA were 120% more likely to undergo readmission within 90 days (P = .021). Patients on depression medication alone were not at increased risk of readmission in the TKA cohort (P = .991). For THA, neither diagnosis appeared a risk factor for readmission (P = .852). Conclusions Patients with depression, anxiety, or both undergoing TKA were at a statistically significant risk of readmission within 90 days compared with patients without these diagnoses. Anxiety and depression were both risk factors for readmission, but anxiety appeared to have a more significant impact. Patients undergoing THA on the other hand did not appear to share this risk profile.
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Affiliation(s)
- Paul Knapp
- Section of Orthopaedic Surgery, Ascension Providence Hospital, Southfield, MI, USA
| | - James T Layson
- Section of Orthopaedic Surgery, Ascension Providence Hospital, Southfield, MI, USA
| | - Waleed Mohammad
- Section of Orthopaedic Surgery, Ascension Providence Hospital, Southfield, MI, USA
| | - Natalie Pizzimenti
- Ascension-Providence Orthopaedic Residency, The MORE Foundation, Novi, MI, USA
| | - David C Markel
- Section of Orthopaedic Surgery, Ascension Providence Hospital and The Core Institute, Novi, MI, USA
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29
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Kamalapathy P, Kurker KP, Althoff AD, Browne JA, Werner BC. The Impact of Mental Illness on Postoperative Adverse Outcomes After Outpatient Joint Surgery. J Arthroplasty 2021; 36:2734-2741. [PMID: 33896669 DOI: 10.1016/j.arth.2021.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/15/2021] [Accepted: 04/02/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The effect of pre-existing mental illness on outpatient surgical outcomes is not well characterized. The objective of this study was to evaluate the association between pre-existing mental illness diagnosis and postoperative complications after outpatient total knee (TKA) and total hip arthroplasty (THA) and 2) compare with inpatient total joint arthroplasty (TJA). METHODS The Mariner Claims Database was used to capture patients undergoing outpatient TJA from 2010 to 2017. Patients were grouped into three categories: those with an existing history of anxiety and/or depression, those with severe mental illness, and those without history of mental illness. Additional subgroup analysis compared those with severe mental illness undergoing outpatient vs inpatient TJA. Outcomes were analyzed using multivariable logistic regression (P < .05). RESULTS Patients undergoing outpatient TJA with prior history of anxiety and/or depression or severe mental illness had an increased risk of emergency department (ED) visits (TKA, P < .001; THA, P = .014) within 90 days compared with those without history of mental illness. Severe mental illness was also associated with increased risk of medical complications at 90 days (TKA, P < .001; THA, P = .006). When compared with those undergoing inpatient surgery, patients undergoing outpatient TKA with severe mental illness were at increased risk of periprosthetic infection (P = .005) and ED visit (P = .003) within 90 days of surgery. CONCLUSION Anxiety/depression and severe mental illness are associated with higher rates of ED visits after outpatient TJA. Patients with severe mental illness also experienced more adverse events, whereas those with anxiety and/or depression had similar rates compared with control. A higher rate of adverse outcomes was seen after TKA in patients with severe mental illness when surgery was performed in the outpatient setting vs those that had surgery as an inpatient. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Pramod Kamalapathy
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Kristina P Kurker
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Alyssa D Althoff
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
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30
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Hernandez NM, Vakharia RM, Mont MA, Roche MW, Seyler TM. Antipsychotic Use Is Associated With Longer In-hospital Lengths of Stay and Higher Rates of Venous Thromboembolism and Costs of Care After Primary Total Knee Arthroplasty. J Am Acad Orthop Surg 2021; 29:e675-e680. [PMID: 34135297 DOI: 10.5435/jaaos-d-20-00726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/16/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Studies have shown that antipsychotic medication use may lead to venous thromboembolisms (VTEs); however, this association has not been demonstrated in patients undergoing primary total knee arthroplasty (TKA). Therefore, the purpose of this study was to investigate whether patients taking antipsychotic medications at the time of their primary TKA have higher rates of in-hospital lengths of stay (LOS), VTEs, and costs of care. METHODS Patients taking antipsychotic medications were identified and matched to a cohort in a 1:5 ratio by age, sex, and medical comorbidities. Patients who had a history of VTEs or hypercoagulable states before their TKA were excluded. The query resulted in 439,579 patients within the study (n = 73,285) and matching cohorts (n = 366,294). Outcomes analyzed included rates of in-hospital LOS, VTEs, and costs of care. A P value less than 0.01 was considered statistically significant. RESULTS We found statistically significant longer in-hospital LOS for patients taking antipsychotic medications (3.27 versus 3.02 days, P < 0.0001). Study patients were also found to have a higher incidence and odds ratio of VTEs (2.37 versus 1.04%; odds ratio: 1.86, 95% confidence interval: 1.75-1.97, P < 0.0001). Ninety-day costs of care were also significantly higher in the study cohort ($17,332.70 versus $15,975.00, P < 0.0001). CONCLUSION After adjusting for confounders, patients taking antipsychotic medication were found to have higher rates of in-hospital LOS, VTEs, and costs of care. The study can be used by orthopaedic surgeons to counsel patients taking these medications concerning the potential complications after their procedure.
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Affiliation(s)
- Nicholas M Hernandez
- From the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Hernandez), Maimonides Medical Center, New York, NY (Vakharia), the Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY (Mont), Orthopaedic Research Institute, Holy Cross Hospital, Ft. Lauderdale, FL (Roche), and the Department of Orthopaedic Surgery, Duke University, Durham, NC (Seyler)
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31
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Seagrave KG, Lewin AM, Harris IA, Badge H, Naylor J. Association between pre-operative anxiety and/or depression and outcomes following total hip or knee arthroplasty. J Orthop Surg (Hong Kong) 2021; 29:2309499021992605. [PMID: 33596736 DOI: 10.1177/2309499021992605] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE While elective primary total hip (THA) and knee (TKA) arthroplasty are effective procedures for addressing the symptoms associated with advanced osteoarthritis, there is evidence to suggest that patient anxiety and depression are linked to poorer outcomes following surgery. METHODS A secondary analysis of prospectively-collected data of people undergoing primary elective THA or TKA for osteoarthritis across 19 hospitals was performed. We assessed outcomes at 1 year post-surgery for people with and without medically treated anxiety and/or depression at the time of surgery (A/D and no-A/D). We used unadjusted and adjusted analyses to compare improvement in Oxford Hip or Knee Scores, the incidences of major post-operative complications, satisfaction and index joint improvement by A/D status. RESULTS 15.2% (254/1669) of patients were identified with anxiety and/or depression at time of surgery. In the unadjusted analysis, the A/D group had greater mean Oxford score improvement by 2.1 points (95% CI 0.8 to 3.4, p = 0.001), increased major complications (OR 1.39, 95% CI 1.05 to 1.85, p = 0.02), were less likely to report a "much better" global improvement for index joint (OR 0.56, 95% CI 0.38 to 0.83, p = 0.003), and there was no statistically significant difference in the rate of satisfaction with the results of surgery (OR 0.64, 95% CI 0.37 to 1.10, p = 0.10). The adjusted analysis found no significant associations between A/D vs. no-A/D and any of the reported outcomes. CONCLUSION After adjustment for confounding variables, people with anxiety and/or depression pre-operatively, compared to those without, have similar outcomes following hip or knee arthroplasty.
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Affiliation(s)
- Kurt G Seagrave
- 4334The University of Sydney School of Medicine, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Adriane M Lewin
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,South West Sydney Clinical School, 7800University of New South Wales, Sydney, New South Wales, Australia
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,South West Sydney Clinical School, 7800University of New South Wales, Sydney, New South Wales, Australia.,South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Helen Badge
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,South West Sydney Clinical School, 7800University of New South Wales, Sydney, New South Wales, Australia.,276979Australian Catholic University, North Sydney, New South Wales, Australia
| | - Justine Naylor
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,South West Sydney Clinical School, 7800University of New South Wales, Sydney, New South Wales, Australia.,South Western Sydney Local Health District, Sydney, New South Wales, Australia
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32
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Functional Outcomes and Health-Related Quality of Life Before and After Primary Total Knee Replacement for Patients From Diverse Geographic Regions. J Arthroplasty 2021; 36:1958-1965. [PMID: 33581972 DOI: 10.1016/j.arth.2021.01.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/30/2020] [Accepted: 01/17/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate whether patient-reported knee function and health status before and after primary total knee replacement (TKR) at an academic medical center differs among patients from diverse geographic regions. METHODS We assessed patient-reported outcomes (PROs) as measured by the Oxford Knee Score (OKS) and EuroQoL-5D (EQ-5D) in 2855 TKR patients at preprimary and one year postprimary TKR procedure between January 1, 2012 and June 30, 2014. We compared the demographic characteristics, response rates, and changes in OKS, EQ-5D, and EQ visual analog scale among local, regional, and national patient groups. Patient- or hospital-related predictors of the postoperative scores were identified after controlling for preoperative scores on the PRO measures. RESULTS Local patients had more comorbid conditions. Groups were similar in clinical outcomes such as length of stay at hospital, complication, and reoperation rates. Local, regional, and national patients had similar response rates and reported a similar level of knee function and health-related quality of life before and after TKR. Eighty nine percent had clinically important improvement on OKS, 69% on EQ-5D index, and 28% EQ visual analog scale, and there were no differences among groups in the proportions of clinically meaningful change. Better postoperative PRO scores were associated with older age, shorter hospital stay, fewer comorbidities, nonsmoking status, fewer complications, and private health insurance. CONCLUSION Some patient characteristics such as comorbidities were greater in the local patient cohort versus the national cohort. Nevertheless, clinical outcomes and PROs were comparable across all geographic tiers.
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Vajapey SP, McKeon JF, Krueger CA, Spitzer AI. Outcomes of total joint arthroplasty in patients with depression: A systematic review. J Clin Orthop Trauma 2021; 18:187-198. [PMID: 34026486 PMCID: PMC8121979 DOI: 10.1016/j.jcot.2021.04.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Depression has been implicated as a poor predictor of outcomes after total joint arthroplasty (TJA) of the lower extremity in some studies. We aimed to determine whether depression as a comorbidity affects the TJA outcomes and whether pain reduction associated with successful TJA alters depressive symptoms. METHODS A search of PUBMED was performed using keywords "depression", "arthroplasty", "depressive disorder", and "outcomes." All English studies published over the last ten years were considered for inclusion. Quantitative and qualitative analysis was then performed on the data. RESULTS Thirty articles met inclusion criteria (16 retrospective, 14 prospective). Three showed that depressed patients were at higher risk for readmission. Two reported that depressed patients had higher likelihood of non-home discharge after TJA compared to non-depressed patients. Four noted that depressed patients incur higher hospitalization costs than non-depressed patients. Ten suggest depression is a predictor of poor patient-reported outcome measures, pain, and satisfaction after TJA. Five suggested the gains depressed patients experience in functional outcome scores after TJA are similar to gains experienced by patients without depression. Another eight suggested that TJA improves not only function and pain but also depressive symptoms in patients with depression. CONCLUSION The results of this review show that depression increases the risk of persistent pain, dissatisfaction, and complications after TJA. Additionally, depressed patients may incur higher costs than non-depressed patients undergoing TJA and may have worse preoperative and postoperative patient reported outcome measures (PROMs). However, the gains in function that depressed patients experience after TJA are equivalent to gains experienced by non-depressed patients and depressed patients may experience improvement in their depressive symptoms after TJA. Patient selection for TJA is critical and counseling regarding increased risk for complications is crucial in depressed patients undergoing TJA.
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Affiliation(s)
- Sravya P. Vajapey
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, USA,Corresponding author. 725 Prior Hall, Columbus, OH, 43210, USA.
| | - John F. McKeon
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, USA
| | - Chad A. Krueger
- Department of Orthopaedic Surgery, The Rothman Institute, USA
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Trinh JQ, Carender CN, An Q, Noiseux NO, Otero JE, Brown TS. Resilience and Depression Influence Clinical Outcomes Following Primary Total Joint Arthroplasty. J Arthroplasty 2021; 36:1520-1526. [PMID: 33334640 DOI: 10.1016/j.arth.2020.11.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/13/2020] [Accepted: 11/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Resilience and depression may impact clinical outcomes following primary total joint arthroplasty (TJA). This study aimed to quantify baseline resilience and depression prevalence in patients undergoing primary TJA and evaluate their influence on patient-reported clinical outcomes. METHODS We prospectively enrolled 98 patients undergoing primary TJA. Exclusion criteria included patients under 18 years of age, undergoing surgery for fracture, or who underwent additional surgery during the study period. Patients completed the Brief Resilience Scale to measure resilience, Patient Health Questionnaire-9 to measure depression, and Patient-Reported Outcomes Measurement Information System-10 to measure global physical and mental health preoperatively and 1 year postoperatively. RESULTS Preoperatively, 22% and 15% of patients demonstrated major and mild depression, respectively. High resilience was identified in 34% of patients, normal resilience in 55%, and low resilience in 11%. Preoperative depression correlated with lower resilience, global physical health, and global mental health scores preoperatively as well as at 1 year after surgery (P < .001). Higher levels of preoperative resilience correlated with higher global physical and mental health scores preoperatively and at 1 year postoperatively (P < .001). CONCLUSION Depression symptoms are common among patients undergoing primary TJA and are associated with worse patient-reported outcomes. Patients with higher levels of resilience have higher global physical and mental health scores before and after TJA. Psychological traits and depression impact clinical outcomes following TJA.
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Affiliation(s)
- Jonathan Q Trinh
- Department of Orthopedics & Rehabilitation, University of Iowa Hospital & Clinics, Iowa City, IA
| | - Christopher N Carender
- Department of Orthopedics & Rehabilitation, University of Iowa Hospital & Clinics, Iowa City, IA
| | - Qiang An
- Department of Orthopedics & Rehabilitation, University of Iowa Hospital & Clinics, Iowa City, IA
| | - Nicolas O Noiseux
- Department of Orthopedics & Rehabilitation, University of Iowa Hospital & Clinics, Iowa City, IA
| | | | - Timothy S Brown
- Department of Orthopedics & Rehabilitation, University of Iowa Hospital & Clinics, Iowa City, IA
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Swiggett SJ, Vakharia AM, Ehiorobo JO, Vakharia RM, Roche MW, Mont MA, Choueka J. Impact of depressive disorders on primary total shoulder arthroplasties: a matched control analysis of 113,648 Medicare patients. Shoulder Elbow 2021; 13:181-187. [PMID: 33897849 PMCID: PMC8039756 DOI: 10.1177/1758573220916846] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/09/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The purpose of this study was to investigate whether patients with depressive disorders undergoing primary total shoulder arthroplasty have higher rates of (1) in-hospital lengths of stay, (2) readmission rates, (3) medical complications, and (4) implant-related complications. METHODS A retrospective query was performed using a national claims database. Study group patients were matched to controls in a 1:5 ratio according to age, sex, and medical comorbidities. The query yielded 113,648 patients who were with (n = 18,953) and without (n = 94,695) depressive disorders. Pearson's χ2 analyses were used to compare patient demographics. Logistic regression analyses were used to calculate odds-ratios of complications and readmission rates. Welch's t-tests were used to test for significance for in-hospital lengths of stay. A p-value less than 0.003 was considered statistically significant. RESULTS Study group patients had significantly longer in-hospital lengths of stay (2.7 days versus 2.3 days; p < 0.0001). Patients who have depressive disorders had higher incidences and odds of readmissions (9.4 versus 6.15%; odds-ratio: 1.6, p < 0.0001), medical complications (2.7 versus 0.9%; odds-ratio: 3.0, p < 0.0001), and implant-related complications (6.1 versus 2.4%; odds-ratio: 2.59, p < 0.0001) compared to controls. CONCLUSION Depressive disorder patients have longer in-hospital lengths of stay and increased odds of readmissions and complications following primary total shoulder arthroplasty.
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Affiliation(s)
- Samuel J Swiggett
- Department of Orthopedic Surgery,
Maimonides Medical Center, Brooklyn, USA,Samuel J Swiggett, Maimonides Medical
Center, 4802, 10th Avenue Brooklyn, NY 11219, USA.
| | - Ajit M Vakharia
- Department of Orthopedic Surgery, Case
Western Reserve University Hospital, Cleveland, USA
| | - Joseph O Ehiorobo
- Department of Orthopedic Surgery,
Northwell Health, Lenox Hill Hospital, New York, USA
| | | | - Martin W Roche
- Holy Cross Hospital, Orthopedic Research
Institute, Ft Lauderdale, USA
| | - Michael A Mont
- Department of Orthopedic Surgery,
Northwell Health, Lenox Hill Hospital, New York, USA,Department of Orthopaedic Surgery,
Cleveland Clinic Hospital, Cleveland, USA
| | - Jack Choueka
- Department of Orthopedic Surgery,
Maimonides Medical Center, Brooklyn, USA
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Wilson JM, Schwartz AM, Farley KX, Bradbury TL, Guild GN. Preoperative Patient Factors and Postoperative Complications as Risk Factors for New-Onset Depression Following Total Hip Arthroplasty. J Arthroplasty 2021; 36:1120-1125. [PMID: 33127239 DOI: 10.1016/j.arth.2020.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/29/2020] [Accepted: 10/09/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Depression is known to be a risk factor for complication following primary total hip arthroplasty (THA), but little is known about new-onset depression (NOD) following THA. The purpose of this study is to determine the incidence of NOD and identify risk factors for its occurrence after THA. METHODS This is a retrospective cohort study of the Truven MarketScan database. Patients undergoing primary THA were identified and separated into cohorts based on the presence or not of NOD. Patients with preoperative depression or a diagnosis of fracture were excluded. Patient demographic and comorbid data were queried, and postoperative complications were collected. Univariate and multivariate regression analysis was then performed to assess the association of NOD with patient-specific factors and postoperative complications. RESULTS In total, 111,838 patients undergoing THA were identified and 2517 (2.25%) patients had NOD in the first postoperative year. Multivariate analysis demonstrated that preoperative opioid use, female gender, higher Elixhauser comorbidity index, preoperative anxiety disorder, drug or alcohol use disorder, and preoperative smoking were associated with the occurrence of NOD (P ≤ .001). The following postoperative complications were associated with increased odds of NOD: prosthetic joint infection (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.42-2.34, P < .001), aseptic revision surgery (OR 1.47, 95% CI 1.06-2.04, P = .019), periprosthetic fracture (OR 1.72, 95% CI 1.13-2.61, P = .01), and non-home discharge (OR 1.59, 95% CI 1.42-1.77, P < .001). CONCLUSIONS NOD is common following THA and there are multiple patient-specific factors and postoperative complications which increase the odds of its occurrence. Providers should use this information to identify at-risk patients so that pre-emptive prevention strategies may be employed.
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Affiliation(s)
- Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | | | - Kevin X Farley
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | | | - George N Guild
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
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Emergency Department Observation Versus Readmission Following total Joint Arthroplasty: Can We Avoid the Bundle Buster? J Arthroplasty 2021; 36:833-836. [PMID: 33036843 DOI: 10.1016/j.arth.2020.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/10/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND As the Center for Medicare and Medicaid (CMS) moves toward bundled payment plans for total joint arthroplasty (TJA), it becomes necessary to reduce factors that increase cost for an episode of care such as readmissions. The goal of this study is to evaluate the payment for observation stay versus readmission for patients who present to the emergency department. METHODS A retrospective review from 2014-2019 was conducted identifying all Medicare patients who had a primary, elective TJA and visited the ED within 90 days postoperatively. If a readmission was one midnight or less or had an equivalent diagnosis to an observation stay patient, it was characterized as a readmission that could have qualified as an observation stay. Using our institution's average payment for Medicare readmissions and observations, actual and potential savings were calculated. RESULTS Sixty-nine out of 523 (13.2%) patients were placed under observation, while 454 (86.8%) patients were readmitted. Eighty-six out of 523 (18.9%) patients qualified for observation status. There was an actual savings of 11.8% by placing patients on observation status and readmission rate was decreased by 13.2%. Savings could have increased by a total of 27.7% and readmissions decreased by a total of 29.6% if all patients who qualified had been placed on observation status. CONCLUSION At our institution, the implementation of observation stay has led to a savings of 11.8% and a potential total savings of 27.7%. The rate of readmissions was decreased by 13.2% and had the potential to decrease by a total of 29.6%.
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Jarvis CA, Bonney PA, Yuan E, Ding L, Chow F, Kim AW, Mack WJ, Zada G, Attenello FJ. Comorbid depression in surgical cancer patients associated with non-routine discharge and readmission. Surg Oncol 2021; 37:101533. [PMID: 33601294 DOI: 10.1016/j.suronc.2021.101533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/20/2021] [Accepted: 02/08/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To characterize the rates of depression across primary cancer sites, and determine the effects of comorbid depression among surgical cancer patients on established quality of care indicators, non-routine discharge and readmission. METHODS Patients undergoing surgical resection for cancer were selected from the Nationwide Readmissions Database (2010-2014). Multivariable analysis adjusted for patient and hospital level characteristics to ascertain the effect of depression on post-operative outcomes and 30-day readmission rates. Non-routine discharge encompasses discharge to skilled nursing, inpatient rehabilitation, and intermediate care facilities, as well as discharge home with home health services. RESULTS Among 851,606 surgically treated cancer patients, 8.1% had a comorbid diagnosis of depression at index admission (n = 69,174). Prevalence of depression was highest among patients with cancer of the brain (10.9%), female genital organs (10.9%), and lung (10.5%), and lowest among those with prostate cancer (4.9%). Depression prevalence among women (10.9%) was almost twice that of men (5.7%). Depression was associated with non-routine discharge after surgery (OR 1.20, CI:1.18-1.23, p < 0.0001*) and hospital readmission within 30 days (OR 1.12, CI:1.09-1.15, p < 0.001*). CONCLUSION Rates of depression vary amongst surgically treated cancer patients by primary tumor site. Comorbid depression in these patients is associated with increased likelihood of non-routine discharge and readmission.
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Affiliation(s)
- Casey A Jarvis
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Phillip A Bonney
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Edith Yuan
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Li Ding
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Frances Chow
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anthony W Kim
- Department of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William J Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Frank J Attenello
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Mahdi A, Hälleberg-Nyman M, Wretenberg P. Reduction in anxiety and depression symptoms one year after knee replacement: a register-based cohort study of 403 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1215-1224. [PMID: 33426612 PMCID: PMC8282573 DOI: 10.1007/s00590-020-02860-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 12/25/2020] [Indexed: 12/30/2022]
Abstract
Background Anxiety and depression are associated with patient dissatisfaction after total knee arthroplasty (TKA). Understanding whether preoperative knee-related symptoms could be a cause of anxiety and depression might help prevent unnecessary delay of surgery for this group of patients. We investigated changes in prevalence of anxiety and depression symptoms one year after TKA, and compared demographic data between patients with and without anxiety and depression symptoms preoperatively. Methods This was a prospective cohort study of 403 patients scheduled for TKA. Data on patient-related outcome measures and the prevalence of anxiety and depression symptoms were collected preoperatively and one year postoperatively. Before–after differences in anxiety/depression prevalence were compared with a chi-square test, and differences in demographic data between the groups with and without anxiety and/or depression symptoms were compared with an independent t test. Results Among the 15% of patients with anxiety symptoms before surgery, 59% had improved in these symptoms one year after surgery; while among the 10% with depression symptoms before surgery, 60% had improved one year after surgery. Patients with preoperative anxiety and/or depression were younger, and had higher body mass index, lower general quality of life (EQ-5D-3L), higher pain scores (visual analog scale), and lower knee-related (KOOS) scores on all subscales except sport. Conclusion Presurgical symptoms of anxiety and depression seem to be partly caused by knee symptoms. Understanding of this issue would offer better strategies to prevent unnecessary delay of surgery in this group of patients.
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Affiliation(s)
- Aamir Mahdi
- Department of Orthopaedics, Örebro County Council, Örebro, Sweden
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Maria Hälleberg-Nyman
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Per Wretenberg
- Department of Orthopaedics, Örebro County Council, Örebro, Sweden
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
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Sveinsdóttir H, Zoëga S, Ingadóttir B, Blöndal K. Symptoms of anxiety and depression in surgical patients at the hospital, 6 weeks and 6 months postsurgery: A questionnaire study. Nurs Open 2021; 8:210-223. [PMID: 33318829 PMCID: PMC7729539 DOI: 10.1002/nop2.620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 07/15/2020] [Accepted: 07/27/2020] [Indexed: 11/12/2022] Open
Abstract
Aims To describe prevalence of symptoms of anxiety and depression in surgical patients at three time points: at hospital postsurgery (T1), 6 weeks (T2) and 6 months (T3) postdischarge from hospital; and detect situations and experiences that predict symptoms of anxiety and depression at T2 and T3. Design Prospective, explorative two-site follow-up study. Methods Patients having selected surgeries from January-July 2016 were invited to participate. Final participation was 390 patients. Participation involved answering questionnaires, including the Hospital Anxiety and Depression Scale (HADS). A stepwise multiple linear regression model was employed to calculate predictors of anxiety and depression. Results The proportion of patients presenting with moderate-to-severe anxiety or depression ranged from 5.4%-20.2% at different times. Major predictors of anxiety at both times were not feeling rested upon awakening and higher scores on HADS-Anxiety at T1 and T2 and at T2 also experiencing more distressing postoperative symptoms. For depression, the major predictors were at both times higher scores on HADS-Depression at T2 and T3 and also at T2 not feeling rested upon awakening and at T3 reporting delayed or very delayed recovery.The four models explained from 43.9%-55.6% of the variance in symptoms of anxiety and depression. Our findings show that patients presenting with psychological distress at the hospital are in a vulnerable position. Also, that benefits of good sleep during the recovery should be emphasized during hospital stay.
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Affiliation(s)
- Herdís Sveinsdóttir
- Faculty of NursingUniversity of IcelandReykjavíkIceland
- Surgical ServicesLandspitali University HospitalReykjavíkIceland
| | - Sigríður Zoëga
- Faculty of NursingUniversity of IcelandReykjavíkIceland
- Surgical ServicesLandspitali University HospitalReykjavíkIceland
| | - Brynja Ingadóttir
- Faculty of NursingUniversity of IcelandReykjavíkIceland
- Surgical ServicesLandspitali University HospitalReykjavíkIceland
| | - Katrín Blöndal
- Faculty of NursingUniversity of IcelandReykjavíkIceland
- Surgical ServicesLandspitali University HospitalReykjavíkIceland
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Lunati MP, Wilson JM, Farley KX, Gottschalk MB, Wagner ER. Preoperative depression is a risk factor for complication and increased health care utilization following total shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:89-96. [PMID: 33317706 DOI: 10.1016/j.jse.2020.04.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The incidence of total shoulder arthroplasty (TSA) continues to increase. Although researchers expect preoperative depression to influence outcomes following primary hip and knee arthroplasty, there is a paucity of data on this relationship after primary TSA. The purpose of this study was to define the relationship between a preoperative diagnosis of depression and postoperative outcomes following TSA. METHODS This was a level III retrospective cohort study. We identified patients undergoing TSA between 2009 and 2017 from the Truven MarketScan database and created 2 cohorts, patients with and without depression. We included patients who were continuously enrolled in the database for 1 year preoperatively and postoperatively. We collected demographic data, complication data, and health care utilization factors and then performed statistical analysis comparing complication and health care utilization between cohorts. This analysis controlled for baseline patient demographic, comorbid, and surgical factors. RESULTS We included 22,623 patients undergoing TSA in this study. Of these, 3209 (14%) had a preoperative diagnosis of depression. Multivariate analysis demonstrated that the following were more common in patients with depression: sepsis (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.14-3.65; P = .022), revision within 1 year (OR, 1.92; 95% CI, 1.45-2.55; P < .001), prosthetic joint infection within 1 year (OR, 1.41; 95% CI, 1.04-1.90; P = .025), return to the operating room for irrigation and débridement (OR, 2.72; 95% CI, 1.67-4.42; P < .001), prosthetic complication (OR, 1.54; 95% CI, 1.26-1.88; P < .001), and wound complication (OR, 1.84; 95% CI, 1.2-2.79; P = .004). Similarly, patients with depression had greater health care utilization including higher odds of non-home discharge (OR, 1.43; 95% CI, 1.3-1.57; P < .001), 90-day readmission (OR, 1.55; 95% CI, 1.3-1.86; P < .001), 90-day emergency department visit (OR, 1.39; 95% CI, 1.23-1.57; P < .001), and extended length of stay (≥3 days; OR, 1.23; 95% CI, 1.12-1.36; P < .001). DISCUSSION AND CONCLUSIONS Depression prior to TSA is common and is associated with increased risk of complications and increased health care utilization following TSA. Determining whether this is a modifiable risk factor requires further investigation.
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Affiliation(s)
- Matthew P Lunati
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Kevin X Farley
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael B Gottschalk
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric R Wagner
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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Brown A, Alas H, Bortz C, Pierce KE, Vasquez-Montes D, Ihejirika RC, Segreto FA, Haskel J, Kaplan DJ, Segar AH, Diebo BG, Hockley A, Gerling MC, Passias PG. Patients with psychiatric diagnoses have increased odds of morbidity and mortality in elective orthopedic surgery. J Clin Neurosci 2020; 84:42-45. [PMID: 33485597 DOI: 10.1016/j.jocn.2020.11.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 10/28/2020] [Accepted: 11/28/2020] [Indexed: 11/29/2022]
Abstract
Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. This study included 412,777 elective orthopedic patients who were concurrently diagnosed with PD within the years 2005 to 2016. 30.2% of PD patients experienced a post-operative complication, compared to 25.1% for non-PD patients (p < 0.001). Mood Disorders (bipolar or depressive disorders) were the most commonly diagnosed PD for all elective Orthopedic procedures, followed by anxiety, then dementia (p < 0.001). Logistic regression analysis found PD to be a significant predictor of higher cost to charge ratio (CCR), length of stay (LOS), and death (all p < 0.001). Between, hand, elbow, and shoulder specialties, spine patients had the highest odds of increased CCR and unfavorable discharge, and the second highest odds of death (all p < 0.001).
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Affiliation(s)
- Avery Brown
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Haddy Alas
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Cole Bortz
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Katherine E Pierce
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Dennis Vasquez-Montes
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Rivka C Ihejirika
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Frank A Segreto
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Jonathan Haskel
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Daniel James Kaplan
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Anand H Segar
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Aaron Hockley
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Michael C Gerling
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA.
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The Cost of Poor Mental Health in Total Joint Arthroplasty. J Arthroplasty 2020; 35:3432-3436. [PMID: 32709561 DOI: 10.1016/j.arth.2020.06.083] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this analysis was to evaluate (1) the impact of depression on resource utilization and financial outcomes in bundled total joint arthroplasty (TJA) and (2) whether similar effects are seen using baseline patient-reported outcome scores. METHODS All elective bundled TJA cases from 2017 to 2018 at an academic system in the New York City area were included. We analyzed variables associated with cost differences seen between patients with and without depression, and between patients with low (<40th percentile) and high baseline (>60th percentile) Veterans RAND 12-Item Health Survey mental component scores (MCSs). We also analyzed whether depression or low MCS could predict worse financial outcomes. RESULTS Our population included 825 patients, 418 with patient-reported outcome scores data. Depression was associated with higher rates of skilled nursing facility (SNF) discharge (42.7% vs 36.5%, P = .04), SNF payments ($16,200 vs $12,100, P = .0002), and average total episode costs ($31,000 vs $27,000, P = .04). Depression predicted bundle cost to be greater than target price (OR 1.82, 95% CI: 1.04-.16; P = .04) and SNF payment greater than 75th percentile (OR: 1.91; 95% CI: 1.00-3.65; P < .05). Similar effects were not seen using MCS. CONCLUSION This is the first study to determine that depression predicts bundle cost greater than target price and SNF payment greater than 75th percentile. Our results emphasize the importance of accurate preoperative assessment of mental health in optimization of care, focusing on attenuating the increased SNF payments associated with depression. As similar effects were not seen using MCS, future studies should analyze the use of validated screening tools for depression, such as the PHQ-9, for more accurate assessments of patient mental health in TJA.
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Schwartz AM, Wilson JM, Farley KX, Roberson JR, Guild GN, Bradbury TL. Modifiability of Depression's Impact on Early Revision, Narcotic Usage, and Outcomes After Total Hip Arthroplasty: The Impact of Psychotherapy. J Arthroplasty 2020; 35:2904-2910. [PMID: 32553794 DOI: 10.1016/j.arth.2020.05.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Depression is known to negatively influence functional recovery, patient satisfaction, narcotic requirements, implant survivorship, and perioperative resource utilization after total hip arthroplasty (THA). The degree to which this effect is modifiable is largely unknown, with mixed results on preoperative pharmacological intervention, and concomitant concerns over side effects. We aim to investigate the influence of psychotherapy before THA on surgical outcomes, medical complications, and resource utilization. METHODS A retrospective chart review of Truven MarketScan Databases was performed to generate 3 cohorts: patients without depression, patients with depression who did not receive preoperative psychotherapy, and patients with depression who received psychotherapy before surgery. Outcomes of interest were resource utilization, surgical and medical complications, narcotic requirements, and 1-year and 3-year revision rates. RESULTS On multivariate analysis, depressed patients who did not receive psychotherapy were more likely to be discharged to inpatient rehabilitation facility (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.10-1.48, P < .001) and require 2 or more postoperative narcotic prescriptions (OR 1.20, 95% CI 1.06-1.37, P = .004) than depressed patients who received psychotherapy. Patients who did not receive psychotherapy were more likely to have continued narcotic requirements within 1 year after surgery (OR 1.23, 95% CI 1.08-1.39, P < .001) and undergo revision at 1 year (OR 1.74, 95% CI 1.17-2.58, P = .006) and 3 years (OR 1.92, 95% CI 1.10-3.34, P = .021) than depressed patients who received psychotherapy. CONCLUSION The negative influence of depression on narcotic requirements, resource utilization, and implant survivorship after THA appears to be modifiable with preoperative psychotherapy.
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Affiliation(s)
- Andrew M Schwartz
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - Kevin X Farley
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - James R Roberson
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - George N Guild
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
| | - Thomas L Bradbury
- Department of Orthopaedic Surgery, Emory Orthopaedics & Spine Center, Atlanta, GA
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Gold PA, Garbarino LJ, Anis HK, Neufeld EV, Sodhi N, Danoff JR, Boraiah S, Rasquinha VJ, Mont MA. The Cumulative Effect of Substance Abuse Disorders and Depression on Postoperative Complications After Primary Total Knee Arthroplasty. J Arthroplasty 2020; 35:S151-S157. [PMID: 32061474 DOI: 10.1016/j.arth.2020.01.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/06/2020] [Accepted: 01/14/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Substance abuse disorder (SUD), alcohol abuse disorder (AUD), and depression have been identified as independent risk factors for complications after total knee arthroplasty (TKA). However, these mental health disorders are highly co-associated, and their cumulative effect on postoperative complications have not been investigated. Therefore, this study aimed to determine if patients who have more than one mental health disorder (SUD, AUD, or depression) were at an increased risk for postoperative complications following TKA. METHODS A total of 11,403 TKA patients were identified from a prospectively collected institutional database between January 1, 2017 and April 1, 2019. Patients who had depression, SUD, and AUD were separated into 7 mental health subgroups including each of these diagnoses alone and their combined permeations. Patient demographics, body mass indices, medical comorbidities, and 15 postoperative complications were collected. Univariate analyses were performed using independent Student's t-tests. Multivariate analyses were then performed to identify odds ratios (ORs) for mental health disorders subgroups associated with complications. RESULTS We found a total of 2073 (18%) patients diagnosed with either SUD (4%), AUD (0.6%), or depression (12%). Univariate analyses showed that depression was associated with mechanical failures (P < .001). SUD was associated with periprosthetic joint infection (PJI) (P < .001), wound complications (P = .022), and aseptic loosening (P = .007). AUD was associated with PJI (P < .001) and deep vein thromboses (P = .003). Multivariate analyses found that AUD (OR: 19.419, P < .001) and SUD (OR:3.693, P = .010) were independent risk factors for PJI. Compared with SUD alone, patients with depression plus SUD were found to have a 4-fold (OR: 13.639, P < .001) and 2-fold (OR:4.401, P = .021) increased risk for PJI and cellulitis, respectively. CONCLUSIONS Patients who had depression, SUD, or AUD were at increased risk for postoperative complications following primary TKA. When patients have more than one mental health diagnosis, their risk for complications was amplified. The results of this study can help identify those patients who are at greater risk of postoperative complications to enable improved preoperative optimization and patient education.
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Affiliation(s)
- Peter A Gold
- Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Luke J Garbarino
- Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Hiba K Anis
- Department of Orthopedic Surgery, The Cleveland Clinic, Cleveland, OH
| | - Eric V Neufeld
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Nipun Sodhi
- Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Jonathan R Danoff
- Department of Orthopedic Surgery, North Shore University Hospital, Manhasset, NY
| | - Sreevathsa Boraiah
- Department of Orthopedic Surgery, North Shore University Hospital, Manhasset, NY
| | - Vijay J Rasquinha
- Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
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Lakomkin N, Hutzler L, Bosco JA. The Relationship Between Medicaid Coverage and Outcomes Following Total Knee Arthroplasty: A Systematic Review. JBJS Rev 2020; 8:e0085. [PMID: 32304495 DOI: 10.2106/jbjs.rvw.19.00085] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to improve patients' ability to undergo this procedure. However, despite this, the role of Medicaid insurance in patient outcomes remains unclear. The purpose of this study was to perform a systematic review of the literature to explore the relationship between preoperative Medicaid insurance status and outcomes following primary total knee arthroplasty. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies examining outcomes in patients who had Medicaid and were undergoing total knee arthroplasty. Studies including complex revision operations or less common indications for total knee arthroplasty were excluded. Data on insurance status, postoperative complications, length of stay, readmissions, and subsequent revision surgical procedures were collected for each article. RESULTS A total of 13 studies showing 6.18 million patients undergoing total knee arthroplasty were included in the qualitative synthesis. Seven analyses described an important association between Medicaid coverage and short-term readmissions, and 2 analyses showed a relationship between Medicaid and prolonged length of stay. However, the included studies did not describe a significant association between Medicaid and postoperative mortality or revision rates. CONCLUSIONS Patients with Medicaid undergoing total knee arthroplasty may be more likely to experience an increased length of stay and to be readmitted postoperatively. The unique factors associated with these patients may help to inform customized perioperative surveillance and optimization to improve outcomes in this group. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nikita Lakomkin
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Lorraine Hutzler
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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Wilson JM, Farley KX, Erens GA, Bradbury TL, Guild GN. Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty. J Arthroplasty 2020; 35:1048-1053. [PMID: 31848077 PMCID: PMC7199643 DOI: 10.1016/j.arth.2019.11.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/30/2019] [Accepted: 11/14/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The incidence of revision total hip (rTHA) and knee (rTKA) arthroplasty continues to increase. Preoperative depression is known to influence outcomes following primary arthroplasty. Despite this, it remains unknown whether the same relationship exists for patients undergoing revision procedures. The purpose of this study, therefore, is to investigate this relationship. METHODS This is a retrospective cohort study. Patients undergoing rTHA and rTKA were identified from the Truven MarketScan database. Patients with a diagnosis of prosthetic joint infection were excluded. Two cohorts were created: those with preoperative depression and those without. We included patients who were enrolled in the database for 1 year preoperatively and postoperatively. Demographic and complication data were collected, and statistical analysis was then performed comparing complications between cohorts. RESULTS A total of 10,017 patients undergoing rTHA and 13,973 patients undergoing rTKA were included in this study. Of these, 1305 (13.1%) and 2012 (14.4%) had depression, respectively. Multivariate analysis found that, after rTHA, preoperative depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, prosthetic joint infection, revision surgery, and increased costs (P < .001). Similarly, following rTKA, depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, revision surgery, and increased costs (P < .001). CONCLUSION Depression before revision total joint arthroplasty is common and is associated with increased risk of complication and increased healthcare resource utilization following both rTHA and rTKA. Further research will be needed to delineate to what degree this represents a modifiable risk factor.
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Affiliation(s)
- Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Kevin X Farley
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Greg A Erens
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Thomas L Bradbury
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - George N Guild
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
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Crijns TJ, Bernstein DN, Teunis T, Gonzalez RM, Wilbur D, Ring D, Hammert WC. The Association Between Symptoms of Depression and Office Visits in Patients With Nontraumatic Upper-Extremity Illness. J Hand Surg Am 2020; 45:159.e1-159.e8. [PMID: 31300225 DOI: 10.1016/j.jhsa.2019.03.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 01/21/2019] [Accepted: 03/08/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Because psychological and social factors increase symptoms and limitations, it is possible that they are also related to higher use of care. METHODS We used a database of an academic outpatient orthopedic department in which patient-reported outcome measures were routinely collected and identified 3,620 patients with de Quervain tendinopathy, ganglion, trapeziometacarpal arthritis, trigger digit, or carpal tunnel syndrome who remained in care at least 3 months. At every office visit, patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Test (CAT), PROMIS Pain Interference CAT, and PROMIS Depression CAT. We conducted multivariable Poisson regression analysis of factors associated with the total number of office visits, accounting for PROMIS scores at the first office visit, age, surgical treatment, sex, diagnosis, and clinician team. RESULTS Operative treatment had the greatest influence on the number of office visits. Other variables associated with the number of visits were female sex, younger age, higher PROMIS Depression scores, and higher Pain Interference scores. CONCLUSIONS Treatment choice had the greatest influence on the number of subsequent visits for atraumatic conditions. The fact that the total number of office visits is associated with greater symptoms of depression and greater pain interference, independent of treatment choice, suggests a relation between mental health and resource use. CLINICAL RELEVANCE Quality improvement efforts and future research might address whether adding strategies to decrease symptoms of depression and optimize coping strategies (to reduce pain interference) might improve upper-extremity health more efficiently than standard treatment alone.
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Affiliation(s)
- Tom J Crijns
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX
| | - David N Bernstein
- URMC Orthopaedics and Rehabilitation, University of Rochester Medical Center, University of Rochester, Rochester, NY
| | - Teun Teunis
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ron M Gonzalez
- URMC Orthopaedics and Rehabilitation, University of Rochester Medical Center, University of Rochester, Rochester, NY
| | - Danielle Wilbur
- URMC Orthopaedics and Rehabilitation, University of Rochester Medical Center, University of Rochester, Rochester, NY
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX.
| | - Warren C Hammert
- URMC Orthopaedics and Rehabilitation, University of Rochester Medical Center, University of Rochester, Rochester, NY
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Patients' experiences of discontentment one year after total knee arthroplasty- a qualitative study. BMC Musculoskelet Disord 2020; 21:29. [PMID: 31937282 PMCID: PMC6961288 DOI: 10.1186/s12891-020-3041-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 01/03/2020] [Indexed: 02/08/2023] Open
Abstract
Background Total knee arthroplasty is a common procedure with generally good results. However, there are still patients who are dissatisfied without known explanation. Satisfaction and dissatisfaction have previously been captured by quantitative designs, but there is a lack of qualitative studies regarding these patients’ experiences. Qualitative knowledge might be useful in creating strategies to decrease the dissatisfaction rate. Methods Of the 348 patients who responded to a letter asking if they were satisfied or dissatisfied with their surgery, 61 (18%) reported discontent. After excluding patients with documented complications and those who declined to participate, semi-structured interviews were conducted with 44 patients. The interviews were analyzed according to qualitative content analysis. The purpose was to describe patients’ experiences of discontentment 1 year after total knee arthroplasty. Results The patients experienced unfulfilled expectations and needs regarding unresolved and new problems, limited independence, and lacking of relational supports. They were bothered by pain and stiffness, and worried that changes were complications as a result of surgery. They described inability to perform daily activities and valued activities. They also felt a lack of relational supports, and a lack of respect and continuity, support from health care, and information adapted to their needs. Conclusion Patient expectation seems to be the major contributing factor in patient discontentment after knee replacement surgery. This qualitative study sheds light on the on the meaning of unfulfilled expectations, in contrast to previous quantitative studies. The elements of unfulfilled expectations need to be dealt with both on the individual staff level and on the organizational level. For instance, increased continuity of healthcare staff and facilities may help to improve patient satisfaction after surgery.
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Mahdi A, Hälleberg-Nyman M, Wretenberg P. Preoperative psychological distress no reason to delay total knee arthroplasty: a register-based prospective cohort study of 458 patients. Arch Orthop Trauma Surg 2020; 140:1809-1818. [PMID: 32720002 PMCID: PMC7560918 DOI: 10.1007/s00402-020-03537-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is effective in alleviating pain and improving function in patients with knee arthritis. Psychological factors are known to affect patient satisfaction after TKA. It is important to determine the effectiveness of TKA in patients with presurgical anxiety and/or depression to avoid excluding them from surgery. MATERIALS AND METHODS A prospective cohort study was conducted on all patients who underwent TKA during 2016-2018. Patients were divided into four groups: with anxiety, without anxiety, with depression, and without depression. Outcome measures comprised both generic and knee-specific instruments. Each patient group was compared regarding changes in outcome measures one year after surgery. Between-group comparison was also performed. RESULTS Of the 458 patients with complete data, 15.3% and 9.6% had experienced presurgical anxiety and depression, respectively. All patient groups displayed statistical (P < 0.001) and clinical improvement in all outcome measures. Patients with presurgical anxiety and/or depression generally displayed less improvement, though the only significant mean differences concerned the Knee Injury and Osteoarthritis Outcome Score (KOOS)-sport score in the non-anxiety and non-depression groups (P = 0.006 and 0.03, respectively), a higher proportion of clinically improved KOOS pain in the non-anxiety group (P = 0.03), and the general health state in the anxiety and depression groups (P = 0.004 and 0.04, respectively). CONCLUSIONS All patients improved in outcome measures 1 year after TKA, regardless of presurgical psychological state. Patients with presurgical anxiety and/or depression benefit greatly from surgery and should not be discriminated against based on presurgical psychological distress, though this fact should not eliminate the preoperative psychological assessment of patients. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Aamir Mahdi
- grid.451792.c0000 0000 8699 6304Department of Orthopaedics, Örebro County Council, Örebro, Sweden ,grid.15895.300000 0001 0738 8966School of Medical Sciences, Örebro University, Örebro, Sweden ,grid.15895.300000 0001 0738 8966Department of Orthopaedics, Faculty of Health and Medicine, Örebro University, SE-701 82 Örebro, Sweden
| | - Maria Hälleberg-Nyman
- grid.15895.300000 0001 0738 8966School of Health Sciences, Örebro University, Örebro, Sweden
| | - Per Wretenberg
- grid.451792.c0000 0000 8699 6304Department of Orthopaedics, Örebro County Council, Örebro, Sweden ,grid.15895.300000 0001 0738 8966School of Medical Sciences, Örebro University, Örebro, Sweden
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