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Sigurdardottir M, Sigurdsson MI, Vias RD, Olafsson Y, Gunnarsdottir I, Sigurdsson EL, Karason S. Preoperative optimization of modifiable risk factors is associated with decreased superficial surgical site infections after total joint arthroplasty: a prospective case-control study. Acta Orthop 2024; 95:392-400. [PMID: 39016247 DOI: 10.2340/17453674.2024.41012] [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: 11/10/2023] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND AND PURPOSE The aim of our study was to investigate change in modifiable risk factors following preoperative optimization and whether risk of superficial surgical site infection (SSI) after total joint arthroplasty (TJA) could be reduced. METHODS This is a prospective study of implementation of a preoperative optimization pathway for patients waiting for primary TJA. Information regarding the intervention arm was collected from January 2019 to January 2021, first at decision for operation and then at preoperative assessment 1 week prior to operation. The control arm was included between August 2018 and September 2020 after receiving conventional preoperative preparation and information gathered at preoperative assessment. Follow up occurred 6 weeks postoperatively for both groups. The primary outcome was postoperative superficial SSI. RESULTS The optimization effort resulted in improvement of weight, anemia, HbA1c, vitamin D, and patient engagement. At preoperative assessment the baseline characteristics of the 2 groups were similar except that the intervention group had substantially more comorbidities. Regarding superficial SSI, association was found with BMI ≥ 30 and HbA1c ≥ 42 mmol/mol in the control group but not in the intervention group. When corrected for differences in ASA classification (reflecting comorbidities), age, and sex, being in the intervention group was associated with lower odds of occurrence of superficial SSI compared with the control group (OR 0.64, 95% confidence interval 0.42-0.97). CONCLUSION We showed that preoperative optimization in a structured cooperation between hospital and primary care was associated with a reduced risk of superficial SSI.
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Affiliation(s)
- Maria Sigurdardottir
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik; Faculty of Medicine, University of Iceland, Reykjavik
| | - Martin Ingi Sigurdsson
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik; Faculty of Medicine, University of Iceland, Reykjavik
| | - Rafael Daniel Vias
- Department of Mathematics, Faculty of Physical Sciences, University of Iceland, Reykjavik
| | - Yngvi Olafsson
- Department of Orthopeadics, Landspitali - The National University Hospital of Iceland, Reykjavik
| | - Ingibjorg Gunnarsdottir
- Department of Clinical Nutrition, Landspitali - The National University Hospital of Iceland, Reykjavik; Faculty of Food Science and Nutrition, University of Iceland
| | - Emil L Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik; Development Centre for Primary Health Care, Reykjavik, Iceland
| | - Sigurbergur Karason
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik; Faculty of Medicine, University of Iceland, Reykjavik.
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Tobin JG, Neel GB, Guareschi AS, Barfield WR, Eichinger JK, Friedman RJ. Delayed elective total shoulder arthroplasty: causes and eventual outcomes. INTERNATIONAL ORTHOPAEDICS 2024; 48:1815-1820. [PMID: 38750258 DOI: 10.1007/s00264-024-06210-8] [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: 01/31/2024] [Accepted: 05/04/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE The purpose of this study is to identify risk factors for delays in planned total shoulder arthroplasty (TSA) and determine the perioperative outcomes of TSAs that experienced a delay. METHODS The American College of Surgeons National Quality Improvement Program (NSQIP) database was queried from 2006 to 2019 for primary TSA. Delayed TSA was defined as surgery that occurred greater than one day after hospital admission. Patient demographics, comorbidities, and post-operative complications were collected and compared; the incidence of delayed TSA was analyzed. RESULTS The delayed patients were older, had a higher BMI, a higher rate of recent prior major surgery, and more comorbidities. Delayed patients had higher rates of postoperative complications, return to the OR, and 30-day readmission. Between 2006 and 2019, the rate of delayed TSA decreased. CONCLUSION Surgeons should take care to ensure that patients with comorbidities undergo thorough preoperative clearance to prevent same-day cancellations and postoperative complications.
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Affiliation(s)
- Jacqueline G Tobin
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, Charleston, SC, 29425, USA
| | - Garrett B Neel
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, Charleston, SC, 29425, USA
| | - Alexander S Guareschi
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, Charleston, SC, 29425, USA
| | - William R Barfield
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, Charleston, SC, 29425, USA
| | - Josef K Eichinger
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, Charleston, SC, 29425, USA
| | - Richard J Friedman
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, Charleston, SC, 29425, USA.
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Ruff GL, Thomas J, Ashkenazi I, Grossman EL, Davidovitch RI, Schwarzkopf R. How Has the Total Hip Arthroplasty Patient Population Changed? A Ten-Year Analysis of Total Hip Arthroplasty Patients From 2013 to 2022: A Retrospective, Single-Center Study. J Arthroplasty 2024:S0883-5403(24)00553-9. [PMID: 38830434 DOI: 10.1016/j.arth.2024.05.081] [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: 09/12/2023] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Over the past decades, utilization of total hip arthroplasty (THA) has steadily increased. Understanding the demographic trends of THA patients can assist in projecting access to care. This study sought to assess the temporal trends in THA patient baseline characteristics and socioeconomic factors. METHODS We retrospectively analyzed 16,296 patients who underwent primary elective THA from January 1, 2013, to December 31, 2022. Demographic data, including age, sex, race, body mass index (BMI), Charlson comorbidity index, insurance, and socioeconomic status, as determined by median income by patients' zip code, were collected. The trends of these data were analyzed using the Mann-Kendall test. RESULTS Over the past decade at our institution, patient age (2013: 62.1 years to 2022: 65.1 years, P = .001), BMI (2013: 29.0 to 2022: 29.5, P = .020), and mean Charlson comorbidity index (2013: 2.4 to 2022: 3.1, P = .001) increased. The proportion of Medicare patients increased from 48.4% in 2013 to 54.9% in 2022 (P = .001). The proportion of African American patients among the THA population increased from 11.3% in 2013 to 13.0% in 2022 (P = .012). Over this period, 90-day readmission and 1-year revision rates did not significantly change (2013: 4.8 and 3.0% to 2022: 3.4 and 1.4%, P = .107 and P = .136, respectively). The proportion of operations using robotic devices also significantly increased (2013: 0% to 2022: 19.1%; P < .001). CONCLUSIONS In the past decade, the average age, BMI, and comorbidity burden of THA patients have significantly increased, suggesting improved access to care for these populations. Similarly, there have been improvements in access to care for African American patients. Along with these changes in patient demographics, we found no change in 90-day readmission or 1-year revision rates. Continued characterization of the THA patient population is vital to understanding this demographic shift and educating future strategies and improvements in patient care.
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Affiliation(s)
- Garrett L Ruff
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
| | - Jeremiah Thomas
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
| | - Itay Ashkenazi
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York; Division of Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Eric L Grossman
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
| | - Roy I Davidovitch
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
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Kebeh M, Dlott CC, Tung WS, Wiznia DH. Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Mental Health and Housing Status-Part Five of the Movement Is Life Special ONJ Series. Orthop Nurs 2024; 43:132-140. [PMID: 38861742 PMCID: PMC11178248 DOI: 10.1097/nor.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
Mental health and housing status have the potential to impact total joint arthroplasty (TJA) outcomes and are common TJA eligibility criteria that prevent patients from receiving surgery. Our aim was to formulate recommendations for how nurse navigators can assist patients with managing mental health and housing concerns. Through discussions with nurse navigators and a literature search across two databases, we gathered information regarding the optimization of mental health and housing status among TJA patients. We observed a lack of standardized protocols for addressing these concerns and literature supporting an increased focus on mental health and housing status, indicating the potential for greater nurse navigator involvement in developing and implementing protocols. We recommend nurse navigators use screening tools to identify mental health and housing concerns and offer the suggested resources to support patients in an effort to improve postoperative outcomes and decrease surgical risks.
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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
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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DeMik DE, Gold PA, Frisch NB, Kerr JM, Courtney PM, Rana AJ. A Cautionary Tale: Malaligned Incentives in Total Hip and Knee Arthroplasty Payment Model Reforms Threaten Promising Innovation and Access to Care. J Arthroplasty 2024; 39:1125-1130. [PMID: 38336300 DOI: 10.1016/j.arth.2024.01.064] [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: 10/03/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
Over the past several years, there have been notable changes and controversies involving Medicare reimbursement for total hip (THA) and total knee arthroplasty (TKA). We have seen the development and implementation of experimental bundled payment model pilot programs goals of improving quality and decreasing overall costs of care during the last decade. Many orthopaedic surgeons have embraced these programs and have demonstrated the ability to succeed in these new models by implementing strategies, such as preservice optimization, to shift care away from inpatient or postdischarge settings and reduce postoperative complications. However, these achievements have been met with continual reductions in surgeon reimbursement rates, lower bundle payment target pricings, modest increases in hospital reimbursement rates, and inappropriate valuations of THA and TKA Common Procedural Terminology (CPT) codes. These challenges have led to an organized advocacy movement and spurred research involving the methods by which improvements have been made throughout the entire episode of arthroplasty care. Collectively, these efforts have recently led to a novel application of CPT codes recognized by payers to potentially capture presurgical optimization work. In this paper, we present an overview of contemporary payment models, summarize notable events involved in the review of THA and TKA CPT codes, review recent changes to THA and TKA reimbursement, and discuss future challenges faced by arthroplasty surgeons that threaten access to high-quality THA and TKA care.
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Affiliation(s)
- David E DeMik
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Peter A Gold
- Panorama Orthopedics & Spine Center, Golden, Colorado
| | | | - Joshua M Kerr
- American Association of Hip and Knee Surgeons, Chicago, Illinois
| | | | - Adam J Rana
- Maine Medical Partners Orthopedics and Sports Medicine, South Portland, Maine
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Nuñez JH, Colomina J, Angles F, Pallisó F, Acosta HF, Mateu D, Novellas M. Routine pretransfusion testing before primary total hip or knee arthroplasty are an expensive and wasteful routine. Systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:1585-1595. [PMID: 38416137 DOI: 10.1007/s00402-024-05243-3] [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: 07/27/2023] [Accepted: 02/17/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes. STUDY METHODS A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed. RESULTS The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9 g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9 g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars. DISCUSSION Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12 g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.
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Affiliation(s)
- Jorge H Nuñez
- Department of Orthopedic Surgery, Hospital Universitari Mútua Terrassa, Plaça del Doctor Robert, 5, Terrassa, Barcelona, 08221, Spain.
- Artro-Esport, Centro Médico Teknon, Carrer de Vilana, 12, Barcelona, 08022, Spain.
| | - Jordi Colomina
- Department of Orthopedic Surgery, University Hospital Santa Maria, Gestió de Serveis Sanitaris, Alcalde Rovira Roure, 44, Lleida, 25198, Spain
- Multidisciplinary Research Group in Musculoskeletal Pathology, Fragility and Pain Treatment, Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré, IRBLleida, Av Alcalde Rovira Roure 80, Lleida, 25198, Spain
| | - Francesc Angles
- Department of Orthopedic Surgery, Hospital Universitari Mútua Terrassa, Plaça del Doctor Robert, 5, Terrassa, Barcelona, 08221, Spain
- Departament de Cirugia, Universitat de Barcelona, Barcelona, Spain
| | - Francesc Pallisó
- Department of Orthopedic Surgery, University Hospital Santa Maria, Gestió de Serveis Sanitaris, Alcalde Rovira Roure, 44, Lleida, 25198, Spain
- Multidisciplinary Research Group in Musculoskeletal Pathology, Fragility and Pain Treatment, Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré, IRBLleida, Av Alcalde Rovira Roure 80, Lleida, 25198, Spain
| | - Héctor F Acosta
- Department of Orthopedic Surgery, University Hospital Santa Maria, Gestió de Serveis Sanitaris, Alcalde Rovira Roure, 44, Lleida, 25198, Spain
- Multidisciplinary Research Group in Musculoskeletal Pathology, Fragility and Pain Treatment, Institut de Recerca Biomèdica de Lleida Fundació Dr. Pifarré, IRBLleida, Av Alcalde Rovira Roure 80, Lleida, 25198, Spain
| | - David Mateu
- Departament de Cirugia, Universitat de Barcelona, Barcelona, Spain
- Department of Orthopaedic Surgery, Consorci Sanitari Integral, Hospital Moisés Broggi, Sant Joan Despí, Barcelona, 08970, Spain
| | - Marga Novellas
- Department of Anaesthesiology, Hospital Universitari Mútua Terrassa, Plaça del Doctor Robert, 5, Terrassa, Barcelona, 08221, España
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Ashy CC, Morningstar JL, Gross CE, Scott DJ. The association of ASA score and outcomes following to.tal ankle arthroplasty. Foot Ankle Surg 2024:S1268-7731(24)00072-9. [PMID: 38594104 DOI: 10.1016/j.fas.2024.03.011] [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: 10/02/2023] [Revised: 02/16/2024] [Accepted: 03/22/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND This study seeks to evaluate the relationship between American Society of Anesthesiologist (ASA) score and postoperative outcomes following TAA. METHODS The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2007 to 2020 to identify 2210 TAA patients. Patients were stratified into low (n = 1328; healthy/mild systemic disease) or high (n = 881; severe/life-threatening systemic disease) ASA score cohorts. RESULTS There was no statistically significant difference in complications, readmission, or reoperation rate based on ASA score. Increased ASA score was significantly associated with longer length of stay (low = 1.69 days, high = 1.98 days; p < .001) and higher rate of adverse discharge (low = 95.3 %, high = 87.4 %; p < .001). CONCLUSION Higher ASA scores (3 and 4) were statically significantly associated with increased length of stay and non-home discharge disposition. These findings are valuable for physicians and patients to consider prior to TAA given the increased utilization of resources and cost associated with higher ASA scores. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Affiliation(s)
- Cody C Ashy
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA.
| | - Joshua L Morningstar
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA.
| | - Christopher E Gross
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA.
| | - Daniel J Scott
- Medical University of South Carolina, Department of Orthopaedics and Physical Medicine, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC 29425, USA.
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Gill VS, Tummala SV, Haglin JM, Sullivan G, Spangehl MJ, Bingham JS. Geographical Differences in Surgeon Reimbursement, Volume, and Patient Characteristics in Primary Total Hip Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00257-2. [PMID: 38522798 DOI: 10.1016/j.arth.2024.03.041] [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: 09/25/2023] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND The purpose of this study was to evaluate changes in regional and national variations in reimbursement to arthroplasty surgeons, procedural volumes, and patient populations for total hip arthroplasty (THA) from 2013 to 2021. METHODS The Medicare Physician and Other Practitioners database was queried for all billing episodes of primary THA for each year between 2013 and 2021. Inflation-adjusted surgeon reimbursement, procedural volume, physician address, and patient characteristics were extracted for each year. Data were stratified geographically based on the United States Census regions and rural-urban commuting codes. Kruskal-Wallis and multivariable regressions were utilized. RESULTS Between 2013 and 2021, the overall THA volume and THAs per surgeon increased at the highest rate in the West (+48.2%, +20.2%). A decline in surgeon reimbursement was seen in all regions, most notably in the Midwest (-20.3%). Between 2013 and 2021, the average number of Medicare beneficiaries per surgeon declined by 12.6%, while the average number of services performed per beneficiary increased by 18.2%. In 2021, average surgeon reimbursement was the highest in the Northeast ($1,081.15) and the lowest in the Midwest ($988.03) (P < .001). Metropolitan and rural areas had greater reimbursement than micropolitan and small towns (P < .001). Patient age, race, sex, Medicaid eligibility, and comorbidity profiles differ between regions. Increased patient comorbidities, when controlling for patient characteristics, were associated with lower reimbursement in the Northeast and West (P < .01). CONCLUSIONS Total hip arthroplasty (THA) volume and reimbursement differ between US regions, with the Midwest exhibiting the lowest increase in volume and greatest decline in reimbursement throughout the study period. Alternatively, the West had the greatest increase in THAs per surgeon. Patient comorbidity profiles differ between regions, and increased patient comorbidity is associated with decreased reimbursement in the Northeast and the West. This information is important for surgeons and policymakers as payment models regarding reimbursement for arthroplasty continue to evolve.
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Affiliation(s)
- Vikram S Gill
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona; Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | | | - Jack M Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Georgia Sullivan
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona; Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | - Mark J Spangehl
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
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Dubin J, Bains S, Ihekweazu UN, Mont MA, Delanois R. Social Determinants of Health in Total Joint Arthroplasty: Income. J Arthroplasty 2024:S0883-5403(24)00236-5. [PMID: 38492822 DOI: 10.1016/j.arth.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024] Open
Affiliation(s)
- Jeremy Dubin
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep Bains
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald Delanois
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
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10
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Radtke LE, Blackburn BE, Kapron CR, Erickson JA, Meier AW, Anderson LA, Gililland JM, Archibeck MJ, Pelt CE. Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch. J Arthroplasty 2024:S0883-5403(24)00028-7. [PMID: 38246314 DOI: 10.1016/j.arth.2024.01.027] [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: 12/01/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center. METHODS All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD. RESULTS Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830). CONCLUSIONS With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.
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Affiliation(s)
- Logan E Radtke
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Brenna E Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Claire R Kapron
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jill A Erickson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Adam W Meier
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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11
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Buchan GBJ, Hecht CJ, Sculco PK, Chen JB, Kamath AF. Improved short-term outcomes for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system compared to manual technique with fluoroscopic assistance. Arch Orthop Trauma Surg 2024; 144:501-508. [PMID: 37740783 DOI: 10.1007/s00402-023-05061-z] [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: 06/12/2023] [Accepted: 09/01/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND While robotic-assisted total hip arthroplasty (RA-THA) has been associated with improved accuracy of component placement, the perioperative and early postoperative outcomes of fluoroscopy-based RA-THA systems have yet to be elucidated. METHODS This retrospective cohort analysis included a consecutive series of patients who received manual, fluoroscopy-assisted THA (mTHA) and fluoroscopy-based RA-THA at a single institution. We compared rates of complications within 90 days of surgery, length of hospital stay (LOS), and visual analog scale (VAS) pain scores. RESULTS No differences existed between groups with respect to demographic data or perioperative recovery protocols. The RA-THA cohort had a significantly greater proportion of outpatient surgeries compared to the mTHA cohort (37.4% vs. 3.8%; p < 0.001) and significantly lower LOS (26.0 vs. 39.5 h; p < 0.001). The RA-THA cohort had a smaller 90-day postoperative complication rate compared to the mTHA cohort (0.9% vs. 6.7%; p = 0.029). The RA-THA cohort had significantly lower patient-reported VAS pain scores at 2-week follow-up visits (2.5 vs. 3.3; p = 0.048), but no difference was seen after 6-week follow visits (2.5 vs. 2.8; p = 0.468). CONCLUSION Fluoroscopy-based RA-THA demonstrates low rates of postoperative complications, improved postoperative pain profiles, and shortened LOS when compared to manual, fluoroscopy-assisted THA.
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Affiliation(s)
- Graham B J Buchan
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Christian J Hecht
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Peter K Sculco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th, New York, NY, 10021, USA
| | - James B Chen
- Mission Orthopaedic Institute, Providence Mission Hospital, Mission Viejo, CA, 92691, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Kebeh M, Dlott CC, Kurek D, Morris JC, Johnson CB, Wiznia DH. Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Diabetes and Cardiovascular Disease-Part 3 of the Movement Is Life Special ONJ Series. Orthop Nurs 2024; 43:2-9. [PMID: 38266257 PMCID: PMC10832337 DOI: 10.1097/nor.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
Diabetes and cardiovascular disease are some of the most common risk factors for complications after total joint arthroplasty (TJA). Preoperative optimization programs are dependent on nurse navigators for coordination of interventions that improve patients' health and surgical outcomes. This article uses information regarding the current practices for diabetes and cardiovascular disease management to provide recommendations for nurse navigators when managing these risk factors prior to TJA. We consulted nurse navigators and conducted a literature review to learn about strategies for addressing diabetes and cardiovascular disease in preoperative optimization programs. Nurse navigators can play a critical role in addressing these conditions by providing patient education and implementing preoperative optimization protocols that incorporate discussion regarding guidelines for diabetes and cardiovascular disease management prior to surgery. This article shares recommendations and resources for nurse navigators to help address diabetes and cardiovascular disease as part of preoperative optimization programs.
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Affiliation(s)
- Martha Kebeh
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Chloe C Dlott
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Donna Kurek
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jensa C Morris
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Charla B Johnson
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Daniel H Wiznia
- Martha Kebeh, BA, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Chloe C. Dlott, BS, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL; and OrthoVirginia, Chesterfield, VA
- Jensa C. Morris, MD, Hospital Medicine Service and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT; and Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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McLellan MA, Donnelly MR, Callan KT, Lung BE, Liu S, DiGiovanni R, McMaster WC, Stitzlein RN, Yang S. The role of preoperative aspartate aminotransferase-to-platelet ratio index in predicting complications following total hip arthroplasty. BMC Musculoskelet Disord 2023; 24:934. [PMID: 38042799 PMCID: PMC10693101 DOI: 10.1186/s12891-023-07063-9] [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: 07/24/2023] [Accepted: 11/25/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate the relationship between preoperative aspartate aminotransferase-to-platelet ratio index (APRI) and postoperative complications following total hip arthroplasty (THA). METHODS All THA for osteoarthritis patients from 2007 to 2020 within the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database were included in this study. Subjects were subsequently divided into cohorts based on APRI. Four groups, including normal range, some liver damage, significant fibrosis, and cirrhosis groups, were created. Comparisons between groups were made for demographics, past medical history, and rate of major and minor complications. Other outcomes included readmission, reoperation, discharge destination, mortality, periprosthetic fracture, and postoperative hip dislocation. Multivariate logistic regression analysis was performed to determine the role of preoperative APRI in predicting adverse outcomes. Statistical significance was set at p < 0.05. RESULTS In total, 104,633 primary THA patients were included in this study. Of these, 103,678 (99.1%) were in the normal APRI group, 444 (0.4%) had some liver damage, 256 (0.2%) had significant fibrosis, and 253 (0.2%) had cirrhosis. When controlling for demographics and relevant past medical history, the abnormal APRI groups had a significantly higher likelihood of major complication, minor complication, intraoperative or postoperative bleeding requiring transfusion, readmission, and non-home discharge (all p < 0.05) compared to normal APRI individuals. CONCLUSIONS Abnormal preoperative APRI is linked with an increasing number of adverse outcomes following THA for osteoarthritis for patients across the United States. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- M A McLellan
- Department of Orthopaedic Surgery, University of California Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA.
| | - M R Donnelly
- Department of Orthopaedic Surgery, New York University, New York, USA
| | - K T Callan
- Department of Orthopaedic Surgery, University of California Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - B E Lung
- Department of Orthopaedic Surgery, University of California Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - S Liu
- Stony Brook School of Medicine, New York, USA
| | - R DiGiovanni
- Department of Orthopaedic Surgery, University of California Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - W C McMaster
- Department of Orthopaedic Surgery, University of California Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - R N Stitzlein
- Department of Orthopaedic Surgery, University of California Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - S Yang
- Department of Orthopaedic Surgery, University of California Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
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Zaboli R, Bahadori M, Jafari H, Mousavi SM, Bahariniya S, Mehdizadeh P, Delavari A. A study of factors affecting the length of hospital stay (LOS) of COVID-19 patients: A qualitative evidence in Iranian hospital. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2023; 12:403. [PMID: 38333181 PMCID: PMC10852180 DOI: 10.4103/jehp.jehp_1576_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/25/2022] [Indexed: 02/10/2024]
Abstract
BACKGROUND The present study aimed to identify the administrators' and physicians' experiences and viewpoints about the factors affecting the length of stay (LOS) of COVID-19 patients and provide valid operational evidence. MATERIALS AND METHODS The current study was carried out qualitatively and phenomenologically on experts, officials, and administrators of hospitals in 2021. Purposeful sampling was performed with the maximum diversity. To achieve a comprehensive view, snowball sampling was conducted. Twenty-one experts in the field of healthcare and emerging diseases participated in this study. Semi-structured interviews were used to collect the data. The study sites were universities of medical sciences and hospitals of the Ministry of Health of Iran. The interview questions included questions about the factors affecting the LOS and strategies for controlling the LOS of COVID-19 patients in infectious units. Text analysis was performed through the content analysis method in MAXQDA-10 software. RESULTS Based on the experts' viewpoints, several factors affected the LOS in COVID-19 patients. These factors were divided into five clinical, preclinical, economic, social, and management subcategories. The proposed solutions included policy solutions (supportive policies, development of home care services, training and culture building, and establishment of clinical guidelines) and operational solutions (drug management, promotion of equipment and facilities, telehealth or telemedicine services, and promotion of clinical and support processes). CONCLUSION One of the main tasks of hospital administrators is identifying the factors affecting the reduction of LOS. Among these factors, clinical and management factors in the hospital are more important and need more planning and attention by hospital officials.
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Affiliation(s)
- Rouhollah Zaboli
- Health Management Research Centre, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohammadkarim Bahadori
- Health Management Research Centre, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hamid Jafari
- Health in Disasters and Emergencies Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Seyed Masood Mousavi
- Health Policy and Management Research Center, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Sajjad Bahariniya
- Health Policy and Management Research Center, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Parisa Mehdizadeh
- Health Management Research Centre, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abdoreza Delavari
- Health Management Research Centre, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Kebeh M, Dlott CC, Kurek D, Morris JC, Wiznia DH. Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Substance Use. Orthop Nurs 2023; 42:334-343. [PMID: 37989152 PMCID: PMC10664865 DOI: 10.1097/nor.0000000000000983] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Abstract
Substance use is one of the most common risk factors contributing to complications following total joint arthroplasty. Preoperative optimization programs can help patients modify or stop substance use. The purpose of this study was to provide recommendations and resources that will help nurse navigators standardize and improve preoperative optimization protocols regarding substance use. In a semistructured format, we asked nurse navigators how smoking, alcohol use, and opioid use were addressed. We conducted a literature review and combined findings with nurse navigator reports to create practice recommendations. We recommend consistently referring patients who smoke to smoking cessation programs; using validated screening tools to evaluate alcohol use and involving internists in caring for patients at risk for withdrawal; and involving pain specialists and local resources to assist patients who use opioids. There is a breadth of resources for managing substance use that nurse navigators can utilize to support stronger and more consistent preoperative optimization protocols.
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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
| | - Donna Kurek
- National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL, USA
- OrthoVirginia, Chesterfield, VA, USA
| | - Jensa C. Morris
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, CT, USA
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, 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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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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McGregor PC, LeDuc R. Preoperative and Perioperative Management of Diabetics Undergoing Elective Foot and Ankle Surgery. Orthop Clin North Am 2023; 54:341-348. [PMID: 37271562 DOI: 10.1016/j.ocl.2023.02.006] [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
Diabetics are a highly comorbid population with an elevated risk profile when undergoing surgery. Proper preparation and management of modifiable risk factors can optimize outcomes in diabetics. A multidisciplinary approach to preoperative optimization, including surgeons, primary care providers, and anesthesiologists, ensures diabetic patients receive comprehensive evaluation before elective surgery. Orthopedic surgeons must understand preoperative optimization goals as they pertain to nutrition, glycemic control, and cardiovascular disease in diabetic patients.
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Affiliation(s)
- Patrick Cole McGregor
- Loyola Medical Center, 2160 South 1st Avenue, Maguire Center, Suite 1700, Maywood, IL 60153, USA.
| | - Ryan LeDuc
- Loyola Medical Center, 2160 South 1st Avenue, Maguire Center, Suite 1700, Maywood, IL 60153, USA
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Forslund JM, Chan PH, Prentice HA, Purdy AC, Khatod M. Preoperative Patient Optimization: Outcomes from Elective Total Joint Arthroplasty in a Large US Healthcare System. J Am Acad Orthop Surg 2023:00124635-990000000-00682. [PMID: 37130370 DOI: 10.5435/jaaos-d-23-00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/01/2023] [Indexed: 05/04/2023] Open
Abstract
INTRODUCTION Patient factors are known to affect outcomes in arthroplasty surgery. A preoperative program to address modifiable factors may aid in more appropriate patient selection. We sought to assess patient selection and 90-day postoperative outcomes for total joint arthroplasty (TJA) candidates before and after implementation of a preoperative optimization protocol. METHODS A retrospective time-trend study using data from an integrated healthcare system's total joint replacement registry was done. The study sample consisted of patients aged 18 years or older who underwent primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis between 2009 and 2019. Patients were divided into two cohorts: procedures performed from 2009 to 2013 ("preoptimization protocol") and those from 2015 to 2019 ("postoptimization protocol"); 2014 was excluded because an evidence-based preoperative patient optimization protocol was progressively implemented throughout the year. Patient characteristics, optimization factors, and 90-day outcomes (including emergency department [ED] visits, readmission, all-cause revision, deep infection, venous thromboembolism, and mortality) were compared between the two cohorts using the Pearson chi-square test or Wilcoxon test. RESULTS The study sample included 25,925 THA and 60,484 TKA. In the THA cohort, 10,364 (40.0%) and 15,561 (60.0%) were from the preoptimization and postoptimization cohorts, respectively. The postoptimization THA cohort saw lower rates of ED visits (12.1% vs. 9.4%, P < 0.001) and readmissions (5.6% vs. 3.8%, P < 0.001). In the TKA cohort, 24,054 (39.8%) and 36,430 (60.2%) were from the preoptimization and postoptimization cohorts, respectively. The postoptimization TKA cohort saw lower rates of ED visits (13.1% vs. 11.9%, P < 0.001), readmissions (5.6% vs. 3.0%, P < 0.001), all-cause revisions (0.5% vs. 0.3%, P = 0.003), venous thromboembolism (1.3% vs. 0.9%, P < 0.001), and mortality (0.3% vs. 0.2%, P = 0.011). DISCUSSION An evidence-based protocol to improve patient selection based on modifiable patient factors was adopted by orthopaedic surgeons in the system and utilization of the protocol before TJA was associated with fewer postoperative complications over time. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Johan M Forslund
- From the Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA (Forslund), the Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, CA (Chan and Prentice), the Department of Surgery, Harbor-University of California, Torrance, CA (Purdy), and the Department of Orthopaedic Surgery, Southern California Permanente Medical Group, West Los Angeles, CA (Khatod)
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Dlott CC, Miguez S, Wilkins SG, Khunte A, Johnson CB, Kurek D, Wiznia DH. Metrics for Monitoring Preoperative Optimization Programs for Total Joint Arthroplasty: A Survey of Orthopaedic Nurses. Orthop Nurs 2023; 42:158-164. [PMID: 37262375 DOI: 10.1097/nor.0000000000000942] [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: 06/03/2023] Open
Abstract
Preoperative optimization programs are becoming more common for patients seeking total joint arthroplasty; yet, limited research has been conducted to monitor the long-term effects of these programs on patient outcomes. Our aim was to develop a set of metrics that programs can use to monitor the success of preoperative optimization programs. As part of a larger survey of orthopaedic nurses, we collected data regarding current monitoring techniques for preoperative optimization programs and the feasibility of collecting specific variables. Surgical factors such as length of stay and 30-day readmissions were most often used to monitor the success of preoperative optimization programs. Surgical factors were the most likely to be accessible using the electronic medical record. Surgical factors and patient characteristics are the most feasible components for programs to monitor in order to track the outcomes of patients participating in preoperative optimization programs.
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Affiliation(s)
- Chloe C Dlott
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Sofia Miguez
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Sarah G Wilkins
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Akshay Khunte
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Charla B Johnson
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Donna Kurek
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Daniel H Wiznia
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
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Olsen AS, Giunta NM, Jamison MP, Chen AF, Fitz W, Iorio R. A Total Knee Arthroplasty Preoperative Optimization Program Managed by an Advanced Practice Provider (Physician Assistant) Decreases Complications and Cost: A Pilot Study. J Arthroplasty 2023; 38:S77-S80. [PMID: 37001621 DOI: 10.1016/j.arth.2023.03.064] [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: 11/13/2022] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Studies have shown that optimizing modifiable risk factors leads to improved outcomes, with decreased lengths of stay (LOS), readmissions, complications, and hospital costs. Our goal was to demonstrate that use of an advanced practice provider, physician assistant (PA), within an orthopaedic practice would support these outcomes. METHODS A preoperative optimization program managed by a PA was instituted at an academic medical center. From November 2019 to December 2022, a pilot group of fifteen (15) consecutive primary total knee arthroplasty (TKA) patients who were successfully optimized with the PA-managed program prior to TKA were matched 2:1 to a cohort of thirty (30) TKA patients who did not undergo optimization. Demographics and the modified readmission risk assessment tool score were used to match patients. Variables evaluated included LOS, emergency department visits, and hospital readmissions within 30 and 90 days after surgery, complications, and hospital costs of care. RESULTS Optimized patients had less complications (P = .004) and significantly shorter (P < .001) mean LOS (1.27 days vs 2.97 days) compared to nonoptimized patients. The difference of hospital cost between cohorts for the primary admission was significant (P = .049). When readmission costs were included, the average hospital cost for the nonoptimized group was significantly higher than the optimized group (P = .018). CONCLUSIONS Preoperative optimization led by a PA demonstrated significant reductions in LOS and the costs of care between optimized and non-optimized patients, along with decreased complications.
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Affiliation(s)
- Adam S Olsen
- Department of Orthopaedic Surgery Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nancy M Giunta
- Department of Orthopaedic Surgery Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Matthew P Jamison
- Department of Orthopaedic Surgery Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Antonia F Chen
- Department of Orthopaedic Surgery Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Wolfgang Fitz
- Department of Orthopaedic Surgery Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Iorio
- Department of Orthopaedic Surgery Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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22
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Dlott CC, Wilkins SG, Miguez S, Khunte A, Johnson CB, Kurek D, Wiznia DH. The Use of Risk Scores in Patient Preoperative Optimization for Total Joint Arthroplasty: A Survey of Orthopaedic Nurse Navigators. Orthop Nurs 2023; 42:123-127. [PMID: 36944208 DOI: 10.1097/nor.0000000000000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Preoperative optimization of patients seeking total joint arthroplasty is becoming more common, and risk scores, which provide an estimate for the risk of complications following procedures, are often used to assist with the preoperative decision-making process. The aim of this study was to characterize the use of risk scores at institutions that utilize nurse navigators in the preoperative optimization process. The survey included 207 nurse navigators identified via the National Association of Orthopaedic Nurses to better understand the use of risk scores in preoperative optimization and the different factors that are included in these risk scores. The study found that 48% of responding nurse navigators utilized risk scores in the preoperative optimization process. These risk scores often included patient comorbidities such as diabetes (85%) and body mass index (87%). Risk scores are commonly used by nurse navigators in preoperative optimization and involve a variety of comorbidities and patient-specific factors.
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Affiliation(s)
- Chloe C Dlott
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, RN, MHA, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Yale School of Medicine, New Haven, CT
| | - Sarah G Wilkins
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, RN, MHA, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Yale School of Medicine, New Haven, CT
| | - Sofia Miguez
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, RN, MHA, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Yale School of Medicine, New Haven, CT
| | - Akshay Khunte
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, RN, MHA, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Yale School of Medicine, New Haven, CT
| | - Charla B Johnson
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, RN, MHA, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Yale School of Medicine, New Haven, CT
| | - Donna Kurek
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, RN, MHA, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Yale School of Medicine, New Haven, CT
| | - Daniel H Wiznia
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, RN, MHA, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Yale School of Medicine, New Haven, CT
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23
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Wall CJ, de Steiger RN, Mulford JS, Lewis PL, Campbell DG. Perception of Perioperative Risk for Arthroplasty Patients: A Poll of Australian Orthopedic Surgeons. J Arthroplasty 2023:S0883-5403(23)00187-0. [PMID: 36849011 DOI: 10.1016/j.arth.2023.02.056] [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: 10/28/2022] [Revised: 01/23/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND There is growing interest in the perioperative management of patients who have indications for hip and knee arthroplasty in the setting of modifiable risk factors such as morbid obesity, poorly controlled diabetes, and smoking. A recent survey of the American Association of Hip and Knee Surgeons (AAHKS) found that 95% of respondents address modifiable risk factors prior to surgery. The aim of this study was to poll Australian arthroplasty surgeons regarding their approach to patients who have modifiable risk factors. METHODS The survey tool used in the AAHKS study was adapted for use in the Australian context and distributed to the membership of the Arthroplasty Society of Australia via SurveyMonkey. There were 77 responses received, representing a response rate of 64%. RESULTS The majority of respondents were experienced, high volume arthroplasty surgeons. Overall, 91% of respondents restricted access to arthroplasty for patients who have modifiable risk factors. There were 72% restricting access for excessive body mass index, 85% for poor diabetic control, and 46% for smoking. Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures. While 49% of surgeons believed that current payment systems did not impair their ability to achieve good outcomes, 58% believed that certain arthroplasty patients would benefit from additional intervention, based on their socioeconomic status. CONCLUSION Over 90% of surgeons who responded address modifiable risk factors prior to surgery. This finding aligns with the practice patterns of AAHKS members, despite differences in healthcare systems.
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Affiliation(s)
- Christopher J Wall
- Department of Orthopaedics, Toowoomba Hospital, Darling Downs Health, Toowoomba, Queensland, Australia; School of Medicine, Rural Clinical School, University of Queensland, South Toowoomba, Queensland, Australia; Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Richard N de Steiger
- Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Epworth Clinical School, The University of Melbourne, Richmond, Victoria, Australia
| | | | - Peter L Lewis
- Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Wakefield Orthopaedic Clinic, Adelaide, South Australia, Australia
| | - David G Campbell
- Wakefield Orthopaedic Clinic, Adelaide, South Australia, Australia; Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
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Campbell DG, Poonnoose PM, Oommen AT, Natesan R. Perception of Perioperative Risk for Arthroplasty Patients: A Poll of Indian Orthopedic Surgeons. J Arthroplasty 2023:S0883-5403(23)00095-5. [PMID: 36773665 DOI: 10.1016/j.arth.2023.02.005] [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: 11/01/2022] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND A survey of the American Association of Hip and Knee Surgeons (AAHKS) reported that 95% of respondents attempted to modify risk factors prior to arthroplasty. This study investigated Indian arthroplasty surgeons' approach to patients who have modifiable risk factors. METHODS The AAHKS survey tool was adapted for Indian surgeons and distributed to the membership of the Indian Society of Hip and Knee Surgeons and Indian Arthroplasty Association via a Survey Monkey. A total of 92 survey responses were received, representing a response rate of 12%. RESULTS Overall, 87% of respondents restricted access to arthroplasty surgery for patients who have modifiable risk factors, but only 51% of respondents reported delays or restricted treatment because of risk factors. Respondents reported that financial implications were more likely to delay or restrict treatment in 97% and social/family reasons in 66%. Poor diabetic control (81%), previous infection (57%), and malnutrition/hypoalbuminemia (47%) were the most frequent modifiable risk factors. There were 82% of surgeons reporting that the patient's socioeconomic status influenced treatment including: 71% of patients who have low socioeconomic status, 57% who do not have insurance, and 45% who have limited social supports. Most surgeons (92%) reported that funding influenced the type of care provided and the choice of implants. CONCLUSION Over 97% of Indian arthroplasty surgeons thought socioeconomic factors impaired access to orthopaedic treatment. Only half the surgeons restricted access for comorbidities and these were more often related to infection risks and diabetes. These findings contrast dramatically to the practice patterns of American AAHKS members.
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Affiliation(s)
- David G Campbell
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, Australia
| | - Pradeep M Poonnoose
- Department of Orthopaedics, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Anil T Oommen
- Unit 2, Department of Orthopaedics, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Rajkumar Natesan
- Department of Joint Replacement Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
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25
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Patel I, Nham F, Zalikha AK, El-Othmani MM. Epidemiology of total hip arthroplasty: demographics, comorbidities and outcomes. ARTHROPLASTY (LONDON, ENGLAND) 2023; 5:2. [PMID: 36593482 PMCID: PMC9808997 DOI: 10.1186/s42836-022-00156-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/22/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Primary THA (THA) is a successful procedure for end-stage hip osteoarthritis. In the setting of a failed THA, revision total hip arthroplasty (rTHA) acts as a salvage procedure. This procedure has increased risks, including sepsis, infection, prolonged surgery time, blood loss, and increased length of stay. Increasing focus on understanding of demographics, comorbidities, and inpatient outcomes can lead to better perioperative optimization and post-operative outcomes. This epidemiological registry study aimed to compare the demographics, comorbidity profiles, and outcomes of patients undergoing THA and rTHA. METHODS A retrospective review of discharge data reported from 2006 to the third quarter of 2015 using the National Inpatient Sample registry was performed. The study included adult patients aged 40 and older who underwent either THA or rTHA. A total of 2,838,742 THA patients and 400,974 rTHA patients were identified. RESULTS The primary reimbursement for both THA and rTHA was dispensed by Medicare at 53.51% and 65.36% of cases respectively. Complications arose in 27.32% of THA and 39.46% of rTHA cases. Postoperative anemia was the most common complication in groups (25.20% and 35.69%). Common comorbidities in both groups were hypertension and chronic pulmonary disease. rTHA indications included dislocation/instability (21.85%) followed by mechanical loosening (19.74%), other mechanical complications (17.38%), and infection (15.10%). CONCLUSION Our data demonstrated a 69.50% increase in patients receiving THA and a 28.50% increase in rTHA from the years 2006 to 2014. The data demonstrated 27.32% and 39.46% complication rate with THA and rTHA, with postoperative anemia as the most common cause. Common comorbidities were hypertension and chronic pulmonary disease. Future analyses into preoperative optimizations, such as prior consultation with medical specialists or improved primary hip protocol, should be considered to prevent/reduce postoperative complications amongst a progressive expansion in patients receiving both THA and rTHA.
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Affiliation(s)
- Ishan Patel
- grid.413184.b0000 0001 0088 6903DMC Orthopaedics & Sports Medicine, 3990 John R Street, Detroit, MI 48201 USA
| | - Fong Nham
- grid.413184.b0000 0001 0088 6903DMC Orthopaedics & Sports Medicine, 3990 John R Street, Detroit, MI 48201 USA
| | - Abdul K. Zalikha
- grid.413184.b0000 0001 0088 6903DMC Orthopaedics & Sports Medicine, 3990 John R Street, Detroit, MI 48201 USA
| | - Mouhanad M. El-Othmani
- grid.239585.00000 0001 2285 2675Department of Orthopaedic Surgery, Columbia University Medical Center, 622 W 168th Street, New York, NY 10032 USA
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26
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Orthopaedic Nurse Navigator Involvement in Preoperative Optimization for Total Joint Arthroplasty. Orthop Nurs 2023; 42:48-52. [PMID: 36702096 DOI: 10.1097/nor.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Patients seeking total joint arthroplasty frequently undergo preoperative optimization with the assistance of nurse navigators to facilitate interactions between patients, consulting services, and the orthopaedic surgical team. Given the enormous impact nurse navigator programs have on reducing postoperative complications, our aim is to characterize the involvement of nurse navigators in preoperative optimization programs across the country. We conducted a survey of nurse navigators identified through the National Association of Orthopaedic Nurses to assess the involvement of nurse navigators in the preoperative optimization process. Sixty-seven percent of responding nurse navigators were involved in preoperative optimization, including components such as heart disease (53%) and poorly controlled diabetes (52%). Orthopaedic nurse navigators are commonly involved in preoperative optimization programs for total joint arthroplasty but most of these involve gated yes/no checklists with limited established referral care pathways. Only some of the programs include standardized referrals for specific medical comorbidities.
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27
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Ng MK, Lam A, Diamond K, Piuzzi NS, Roche M, Erez O, Wong CHJ, Mont MA. What are the Causes, Costs and Risk-Factors for Emergency Department Visits Following Primary Total Hip Arthroplasty? An Analysis of 1,018,772 Patients. J Arthroplasty 2023; 38:117-123. [PMID: 35863689 DOI: 10.1016/j.arth.2022.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/26/2022] [Accepted: 07/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Well-powered studies analyzing the relationship and nature of emergency department (ED) visits following primary total hip arthroplasties (THAs) are limited. The aim of this study was to: 1) compare baseline demographics of patients with/without an ED visit; 2) determine leading causes of ED visits; 3) identify patient-related risk factors; and 4) quantify 90-day episode-of-care healthcare costs divided by final diagnosis. METHODS Patients undergoing primary THA between January 1, 2010 and October 1, 2020 who presented to the ED within 90-days postoperatively were identified using the Mariner dataset of PearlDiver, yielding 1,018,772 patients. This included 3.9% (n = 39,439) patients who did and 96.1% (n = 979,333) who did not have an ED visit. Baseline demographics between the control/study cohorts, ED visit causes, risk-factors, and subsequent costs-of-care were analyzed. Using Bonferroni-correction, a P-value less than 0.002 was considered statistically significant. RESULTS Patients who presented to the ED post-operatively were most often aged 65-74 years old (41.09%) or female sex (55.60%). Nonmusculoskeletal etiologies comprised 66.8% of all ED visits. Risk factors associated with increased ED visits included alcohol abuse, depressive disorders, congestive heart failure, coagulopathy, and electrolyte/fluid derangements (P < .001 for all). Pulmonary ($28,928.01) and cardiac ($28,574.69) visits attributed to the highest costs of care. CONCLUSION Nonmusculoskeletal causes constituted the majority of ED visits. The top five risk factors associated with increased odds of ED visits were alcohol abuse, electrolyte/fluid derangements, congestive heart failure, coagulopathy, and depression. This study highlights potential areas of pre-operative medical optimization that may reduce ED visits following primary THA.
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Affiliation(s)
- Mitchell K Ng
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Aaron Lam
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Keith Diamond
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Nicolas S Piuzzi
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, Cleveland, Ohio
| | - Martin Roche
- Hospital for Special Surgery, Department of Orthopaedic Surgery, West Palm Beach, Florida
| | - Orry Erez
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Che Hang Jason Wong
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Michael A Mont
- Hospital for Special Surgery, Department of Orthopaedic Surgery, West Palm Beach, Florida; Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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Dlott CC, Metcalfe T, Jain S, Bahel A, Donnelley CA, Wiznia DH. Preoperative Risk Management Programs at the Top 50 Orthopaedic Institutions Frequently Enforce Strict Cutoffs for BMI and Hemoglobin A1c Which May Limit Access to Total Joint Arthroplasty and Provide Limited Resources for Smoking Cessation and Dental Care. Clin Orthop Relat Res 2023; 481:39-47. [PMID: 35862861 PMCID: PMC9750556 DOI: 10.1097/corr.0000000000002315] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/17/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Performing elective orthopaedic surgery on patients with high BMI, poorly controlled hyperglycemia, and who use tobacco can lead to serious complications. Some surgeons use cutoffs for BMI, hemoglobin A1c, and cigarette smoking to limit surgery to patients with lower risk profiles rather than engaging in shared decision-making with patients about those factors. Other studies have suggested this practice may discriminate against people of lower income levels and women. However, the extent to which this practice approach is used by orthopaedic surgeons at leading hospitals is unknown. QUESTIONS/PURPOSES (1) How often are preoperative cutoffs for hemoglobin A1c and BMI used at the top US orthopaedic institutions? (2) What services are available at the top orthopaedic institutions for weight loss, smoking cessation, and dental care? (3) What proportion of hospital-provided weight loss clinics, smoking cessation programs, and dental care clinics accept Medicaid insurance? METHODS To investigate preoperative cutoffs for hemoglobin A1c and BMI and patient access to nonorthopaedic specialists at the top orthopaedic hospitals in the United States, we collected data on the top 50 orthopaedic hospitals in the United States as ranked by the 2020 US News and World Report 's "Best Hospitals for Orthopedics" list. We used a surgeon-targeted email survey to ascertain information regarding the use of preoperative cutoffs for hemoglobin A1c and BMI and availability and insurance acceptance policies of weight loss and dental clinics. Surgeons were informed that the survey was designed to assess how their institution manages preoperative risk management. The survey was sent to one practicing arthroplasty surgeon, the chair of the arthroplasty service, or department chair, whenever possible, at the top 50 orthopaedic institutions. Reminder emails were sent periodically to encourage participation from nonresponding institutions. We received survey responses from 70% (35 of 50) of hospitals regarding the use of preoperative hemoglobin A1c and BMI cutoffs. There was no difference in the response rate based on hospital ranking or hospital region. Fewer responses were received regarding the availability and Medicaid acceptance of weight loss and dental clinics. We used a "secret shopper" methodology (defined as when a researcher calls a facility pretending to be a patient seeking care) to gather information from hospitals directly. The use of deception in this study was approved by our institution's institutional review board. We called the main telephone line at each institution and spoke with the telephone operator at each hospital asking standardized questions regarding the availability of medical or surgical weight loss clinics, smoking cessation programs, and dental clinics. When possible, researchers were referred directly to the relevant departments and asked phone receptionists if the clinic accepted Medicaid. We were able to contact every hospital using the main telephone number. Our first research question was answered using solely the surgeon survey responses. Our second and third research questions were addressed using a combination of the responses to the surgeon surveys and specific hospital telephone calls. RESULTS Preoperative hemoglobin A1c cutoffs were used at 77% (27 of 35) of responding institutions and preoperative BMI cutoffs were used at 54% (19 of 35) of responding institutions. In the secret shopper portion of our study, we found that almost all the institutions (98% [49 of 50]) had a medical weight loss clinic, surgical weight loss clinic, or combined program. Regarding smoking cessation, 52% (26 of 50) referred patients to a specific department in their institution and 18% (9 of 50) referred to a state-run smoking cessation hotline. Thirty percent (15 of 50) did not offer any internal resource or external referral for smoking cessation. Regarding dental care, 48% (24 of 50) of institutions had a dental clinic that performed presurgical check-ups and 46% (23 of 50) did not offer any internal resource or external referral for dental care. In the secret shopper portion of our study, for institutions that had internal resources, we found that 86% (42 of 49) of weight loss clinics, 88% (23 of 26) of smoking cessation programs, and 58% (14 of 24) of dental clinics accepted Medicaid insurance. CONCLUSION Proceeding with TJA may not be the best option for all patients; however, surgeons and patients should come to this consensus together after a thoughtful discussion of the risks and benefits for that particular patient. Future research should focus on how shared decision-making may influence patient satisfaction and a patient's ability to meet preoperative goals related to weight loss, glycemic control, smoking cessation, and dental care. Decision analyses or time trade-off analyses could be implemented in these studies to assess patients' tolerance for risk. CLINICAL RELEVANCE Orthopaedic surgeons should engage in shared decision-making with patients to develop realistic goals for weight loss, glycemic control, smoking cessation, and dental care that consider patient access to these services as well as the difficulties patients experience in losing weight, controlling blood glucose, and stopping smoking.
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Affiliation(s)
- Chloe C. Dlott
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Tanner Metcalfe
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Sanjana Jain
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Anchal Bahel
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Claire A. Donnelley
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
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Goldner H, Barfchin S, Fingado EK, Loiselle C, Rappaport DI. Preoperative Hospitalist Telehealth Visits for Medically Complex Children During the COVID-19 Pandemic. Hosp Pediatr 2022; 12:e428-e432. [PMID: 36382394 DOI: 10.1542/hpeds.2021-006184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND During the coronavirus disease 2019 pandemic, telehealth has emerged as an alternative to in-person visits. Our children's hospital's preoperative program includes a pediatric hospitalist evaluation of medically complex patients undergoing elective orthopedic surgery. Starting in March 2020, patients were offered either in-person or telehealth preoperative visits. Few data exist regarding preoperative telehealth for medically complex children. We sought to assess this program's practicality and compare clinical characteristics, demographic data, and visit outcome data of patients seen via telehealth versus those seen in person. METHODS We retrospectively collected demographic or clinical data, visit characteristics, and visit outcome data of medically complex children scheduled for orthopedic surgery seen April-October 2020. We reviewed the data to compare characteristics of patients seen in person to those seen via telehealth. RESULTS We reviewed 68 visits: 34 (50%) telehealth and 34 (50%) in-person. There was no statistically significant difference in telehealth use by primary language, insurance type, underlying medical condition, gross motor function classification system score, or technology dependence. There was no significant difference between the median number of hospitalist recommendations (4 telehealth vs 3 in-person, P = .553) or progression to surgery (32 vs 32, odds ratio 1.000, confidence interval 0.133-7.540) on the basis of visit type. CONCLUSIONS A preoperative telehealth program is practical for medically complex children. We found no significant difference in telehealth use between technology-dependent patients and those who are not. Further study of preoperative telehealth visits will hopefully be broader in scope.
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Affiliation(s)
- Hayley Goldner
- General Academic Pediatrics, Nemours Children's Health, Wilmington, Delaware.,Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sahar Barfchin
- General Academic Pediatrics, Nemours Children's Health, Wilmington, Delaware.,Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Emily K Fingado
- General Academic Pediatrics, Nemours Children's Health, Wilmington, Delaware.,Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Claire Loiselle
- General Academic Pediatrics, Nemours Children's Health, Wilmington, Delaware
| | - David I Rappaport
- General Academic Pediatrics, Nemours Children's Health, Wilmington, Delaware.,Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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Szilágyiné Lakatos T, Lukács B, Veres-Balajti I. Cost-Effective Healthcare in Rehabilitation: Physiotherapy for Total Endoprosthesis Surgeries from Prehabilitation to Function Restoration. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15067. [PMID: 36429801 PMCID: PMC9690524 DOI: 10.3390/ijerph192215067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 06/16/2023]
Abstract
Knee and hip joint replacements for the elderly are increasingly placing a burden on healthcare. Our aim was to verify the efficiency of the prehabilitation program among patients with knee arthroplasty (TKA) and hip arthroplasty (THA), taking into account the length and cost of postoperative rehabilitation and the restoration of function. We introduced a two-week preoperative physiotherapy program for patients awaiting knee and hip replacement surgery. We measured the duration and costs of the hospital stays, the active and passive range of motion of the hip and knee joints, and the quality of life. In the study, 99 patients participated (31 male, 68 female), with a mean age of 69.44 ± 9.69 years. We showed that, as a result of the prehabilitation program, the length of postoperative hospital stay decreased (THA: median 31.5 (IQR 26.5-32.5) vs. median 28 (IQR 21-28.5), TKA: median 36.5 (IQR 28-42) vs. median 29 (IQR 26-32.5)), and the patients' quality of life showed a significant improvement (TKA: median 30.5 (IQR 30-35) vs. median 35 (IQR 33-35), THA: median 25 (IQR 25-30) vs. median 33 (IQR 31.5-35)). The flexion movements were significantly improved through prehabilitation in both groups. Based on our positive results, we recommend the introduction of prehabilitation into TKA- and THA-related care.
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Affiliation(s)
- Tünde Szilágyiné Lakatos
- Clinical Center Gyula Kenezy Campus Clinic of Medical Rehabilitation and Physical Medicine, University of Debrecen, 4031 Debrecen, Hungary
| | - Balázs Lukács
- Department of Physiotherapy, Faculty of Health Sciences, University of Debrecen, 4028 Debrecen, Hungary
| | - Ilona Veres-Balajti
- Department of Physiotherapy, Faculty of Health Sciences, University of Debrecen, 4028 Debrecen, Hungary
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Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Cardiovascular Health Disparities. J Am Acad Orthop Surg 2022; 30:1069-1073. [PMID: 35297810 DOI: 10.5435/jaaos-d-21-00920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/03/2022] [Indexed: 02/01/2023] Open
Abstract
Cardiovascular disease includes a collection of conditions with 6.7% of American adults having coronary artery disease and 45% having hypertension. Proper management of these conditions is low (<25%). Hypertension is highest among African Americans and is associated with lower socioeconomic status and education level. Heart disease is associated with postoperative complications, such as cardiovascular and cerebrovascular events, pulmonary and coagulopathy complications, and mortality. Underserved communities can be optimized beginning with a thorough preoperative assessment, which includes evaluating for food security, instituting dietary modifications and exercise regimens, and improving cardiovascular health with pharmacologic modalities and specialty care. Nurse navigators can be invaluable for guiding patients through a cardiovascular preoperative optimization pathway.
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Lin E, Bozic KJ, Ibrahim S, O'Connor MI, Nelson CL. Does Value-Based Care Threaten Joint Arthroplasty Access for Vulnerable Patient Populations?: AOA Critical Issues. J Bone Joint Surg Am 2022; 104:e92. [PMID: 35841318 DOI: 10.2106/jbjs.21.01332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Health-care expenses have been projected to increase from 17.7% of the U.S. gross domestic product (GDP) in 2014 to 19.6% in 2024. The unsustainable increase in health-care costs has contributed toward support for value-based health care (VBHC) reform. Contemporary VBHC reform programs relevant to orthopaedic surgery include the voluntary Bundled Payments for Care Improvement initiatives (BPCI and BPCI-Advanced) and the Comprehensive Care for Joint Replacement (CJR) program, a mandatory bundled payment program.The purported benefits of transitioning from volume-based reimbursement to value-based reimbursement include moving from a fragmented provider-centered care model to a patient-centered model, with greater care coordination and alignment among providers focused on improving value. VBHC models allow innovative strategies to proactively invest resources to promote value (e.g., the use of nurse navigators) while eliminating unnecessary resources that do not promote value. However, major concerns regarding VBHC include the absence of medical and socioeconomic risk stratification as well as decreased access for higher-risk patients.This article identifies the benefits and potential unintended consequences of VBHC reform, with a focus on joint arthroplasty. We also discuss some potential strategies to promote innovation and improve value without compromising access for vulnerable patients.
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Affiliation(s)
- Eugenia Lin
- Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Kevin J Bozic
- Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Said Ibrahim
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Mary I O'Connor
- Vori Health, Jacksonville Beach, Florida.,Movement is Life, Washington, D.C
| | - Charles L Nelson
- Movement is Life, Washington, D.C.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Mental Health Disparities. J Am Acad Orthop Surg 2022; 30:1023-1027. [PMID: 35262515 DOI: 10.5435/jaaos-d-21-00414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 01/31/2022] [Indexed: 02/01/2023] Open
Abstract
Mental illness affects 20.6% of American adults. The lifetime prevalence of depression and anxiety is 17% and 29%, respectively. In particular, women suffer more from mental illness than men. Racial and ethnic minorities experience disproportionate discrimination, which has been linked to depression, anxiety, and psychological distress. African Americans are more likely to be chronically depressed, have higher levels of impairment and more severe symptoms, and often have challenges accessing treatment. Poor mental health is associated with low socioeconomic status, prolonged hospital stays, psychosis, postoperative anemia, infection, and pulmonary embolism. For total hip and knee arthroplasty, mental health conditions have been linked to higher hospital charges, higher rates of nonroutine discharges, and an increased Charlson Comorbidity Index. Mechanisms to address mental health are varied and range from psychosocial to pharmacologic modalities. Optimization in these vulnerable patients includes appropriate preoperative screening, assessment of support systems, identifying resources, and providing a safe discharge plan.
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Movement is Life-Optimizing Patient Access to Total Joint Arthroplasty: The Relationship Between Preoperative Optimization and Healthcare Disparities. J Am Acad Orthop Surg 2022; 30:1005-1006. [PMID: 35452425 DOI: 10.5435/jaaos-d-21-00730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 02/01/2023] Open
Abstract
In coordination with Movement is Life, a multistakeholder coalition dedicated to promoting musculoskeletal health equity, the JAAOS Editorial Board has overseen the preparation of 12 articles that focus on methodology to optimize patients and improve access to total hip and knee arthroplasty for underserved populations.
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Dlott CC, Wiznia DH. CORR Synthesis: How Might the Preoperative Management of Risk Factors Influence Healthcare Disparities in Total Joint Arthroplasty? Clin Orthop Relat Res 2022; 480:872-890. [PMID: 35302972 PMCID: PMC9029894 DOI: 10.1097/corr.0000000000002177] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/24/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Chloe C. Dlott
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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36
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Morse KW, Heinz NK, Abolade JM, Wright-Chisem J, Alice Russell L, Zhang M, Mirza S, Pearce-Fisher D, Orange DE, Figgie MP, Sculco PK, Goodman SM. Factors Associated With Increasing Length of Stay for Rheumatoid Arthritis Patients Undergoing Total Hip Arthroplasty and Total Knee Arthroplasty. HSS J 2022; 18:196-204. [PMID: 35645648 PMCID: PMC9096994 DOI: 10.1177/15563316221076603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/05/2021] [Indexed: 12/12/2022]
Abstract
Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are cost-effective procedures that decrease pain and improve health-related quality of life for patients with advanced symptomatic arthritis, including rheumatoid arthritis (RA). Patients with RA have a longer length of stay (LOS) after THA or TKA than patients with osteoarthritis, yet the factors contributing to LOS have not been investigated. Purpose: We sought to identify the factors contributing to LOS for patients with RA undergoing THA and TKA at a single tertiary care orthopedic specialty hospital. Methods: We retrospectively reviewed data from a prospectively collected cohort of 252 RA patients undergoing either THA or TKA. Demographics, RA characteristics, medications, serologies, and disease activity were collected preoperatively. Linear regression was performed to explore the relationship between LOS (log-transformed) and possible predictors. A multivariate model was constructed through backward selection using significant predictors from a univariate analysis. Results: Of the 252 patients with RA, 83% were women; they had a median disease duration of 14 years and moderate disease activity at the time of arthroplasty. We had LOS data on 240 (95%) of the cases. The mean LOS was 3.4 ± 1.5 days. The multivariate analysis revealed a longer LOS for RA patients who underwent TKA versus THA, were women versus men, required a blood transfusion, and took preoperative opioids. Conclusion: Our retrospective study found that increased postoperative LOS in RA patients undergoing THA or TKA was associated with factors both non-modifiable (type of surgery, sex) and modifiable (postoperative blood transfusion, preoperative opioid use). These findings suggest that preoperative optimization of the patient with RA might focus on improving anemia and reducing opioid use in efforts to shorten LOS. More rigorous study is warranted.
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Affiliation(s)
- Kyle W. Morse
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA,Kyle W. Morse, MD, Department of Medicine,
Hospital for Special Surgery, 535 E 70th St., New York, NY 10021, USA.
| | - Nicole K. Heinz
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA
| | - Jeremy M. Abolade
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA
| | | | - Linda Alice Russell
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA,Department of Medicine, Weill Cornell
Medicine, New York, NY, USA
| | - Meng Zhang
- Department of Medicine, Feinstein
Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Serene Mirza
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA
| | | | - Dana E. Orange
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA,Rockefeller University, New York, NY,
USA
| | - Mark P. Figgie
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA,Department of Medicine, Weill Cornell
Medicine, New York, NY, USA
| | - Peter K. Sculco
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA,Department of Medicine, Weill Cornell
Medicine, New York, NY, USA
| | - Susan M. Goodman
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA,Department of Medicine, Weill Cornell
Medicine, New York, NY, USA
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D'Amore T, Blaber O, Magnuson JA, Sutton RM, Haag T, Krueger CA. Orthopedic Specialty Hospital Reasons for Transfer and Subsequent Outcomes. J Arthroplasty 2022; 37:819-823. [PMID: 35093549 DOI: 10.1016/j.arth.2022.01.058] [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: 12/08/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Surgical specialty hospitals provide patients, surgeons, and staff with a streamlined approach to elective surgery but may not be equipped to handle all complications arising postoperatively. The purpose of this study is to evaluate the immediate postoperative and 90-day outcomes of patients who were transferred from a high-volume specialty hospital following primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS All patients who were admitted to one orthopedic specialty hospital for primary THA or TKA between January 2015 and December 2019, and subsequently transferred to a tertiary care hospital, were identified and propensity matched to nontransferred patients. Emergency department visits, complications, readmissions, mortality, and revisions within 90 days of surgery were identified for each group. RESULTS There were 26 TKAs (0.78%) and 20 THAs (0.48%) transferred, representing 0.62% of all primary THAs and TKAs performed over the study duration. Arrhythmia and chest pain were the most common reasons for transfer. Ninety-day readmissions were significantly higher in the transfer group (15.2% vs 4.3%, P = .020) with an odds ratio for readmission after transfer of 3.9 (95% confidence interval 1.3-12.4). Overall complications and orthopedic complications did not differ significantly, although transferred patients had a higher rate of medical complications (13.0% vs 2.2%, P = .008) with an odds ratio of 6.7 (95% confidence interval 1.6-28.2). CONCLUSION Transfer from a specialty hospital is rarely required following primary TKA and THA. Although not at increased risk for orthopedic complications, these transferred patients are at increased risk for readmissions and medical complications within the first 90 days of their care, necessitating increased vigilance.
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Affiliation(s)
- Taylor D'Amore
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Olivia Blaber
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Justin A Magnuson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Ryan M Sutton
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Tyler Haag
- Rothman Orthopaedic Specialty Hospital, Bensalem, PA
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Black and Hispanic Patients Do Not Stay Longer After Primary Total Knee Arthroplasty: Results From an Urban Center Serving a Predominantly Minority Cohort. J Am Acad Orthop Surg 2022; 30:329-337. [PMID: 35157628 DOI: 10.5435/jaaos-d-21-00609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 12/23/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Previous reports identified minority race/ethnicity to be an independent risk factor for prolonged length of stay (LOS); however, these cohorts consisted of predominantly White patients. This study sought to evaluate minority status as an independent risk factor for prolonged LOS after primary total knee arthroplasty (TKA) in a predominantly Hispanic and Black cohort. METHODS This was a retrospective study using an institutional database of patients who underwent primary TKA between the years 2016 and 2019. Demographic and socioeconomic data, smoking, body mass index (BMI), medical comorbidities, discharge disposition, and 30-day readmission rates were collected. Patients were first categorized into racial/ethnic groups (Hispanic, Black, or White). An univariate analysis was performed comparing patient characteristics between racial/ethnic groups using the Wilcoxon rank sum, chi-squared, and Fisher exact tests. We then categorized patients into two groups-normal LOS (discharged on postoperative day 1 to 2) and prolonged LOS (discharged after postoperative day 2). An univariate analysis was again performed comparing patient characteristics between LOS groups using Wilcoxon rank sum, chi-squared, and Fisher exact tests. After identifying risk factors markedly associated with LOS, a multivariate logistic regression analysis was performed to identify independent risk factors for prolonged LOS. RESULTS A total of 3,093 patients were included-47.9% Hispanic and 38.3% Black. Mean LOS was 2.9 ± 1.6 days. An univariate analysis found race/ethnicity, age, low socioeconomic status (SES), discharge disposition, insurance type, weekday of surgery, BMI >40, smoking, increased American Society of Anesthesiologists (ASA)/Charlson Comorbidity Index (CCI) and several medical comorbidities to be associated with prolonged LOS (P < 0.05). A multivariate logistic regression analysis found Black and Hispanic patients were less likely to have prolonged LOS after adjusting for associated risk factors. White race/ethnicity, nonhome discharge, low SES, weekday of surgery, smoking, BMI >40, and increased ASA and CCI were identified as independent risk factors for prolonged LOS (P < 0.05). The overall 30-day readmission rate was 3.6%, with no notable difference between racial/ethnic and LOS groups (P = 0.98 and P = 0.78). CONCLUSION In contrast to previous reports, our study found that after adjusting for associated risk factors, minority patients do not have prolonged LOS after primary TKA in an urban, socioeconomically disadvantaged, predominantly minority patient cohort. White race/ethnicity, nonhome discharge, low SES, weekday of surgery, smoking, BMI >40, increased CCI, and ASA were all found to be independent risk factors for prolonged LOS. These findings highlight the need to further investigate the role of race/ethnicity on LOS after primary TKA using large-scale, randomized controlled trials with equally represented patient cohorts.
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Cole WW, Familia M, Miskimin C, Mulcahey MK. Preoperative Optimization and Tips to Avoiding Surgical Complications Before the Incision. Sports Med Arthrosc Rev 2022; 30:2-9. [PMID: 35113836 DOI: 10.1097/jsa.0000000000000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In preparation for surgery, it is important for surgeons to have a detailed discussion with patients about the risks, benefits, and alternatives to surgery. Patient optimization, ensuring the patient is in the best medical condition before surgery, is also an important aspect of patient care that the surgeon must consider. Although complications cannot be eliminated, there are often opportunities to optimize patients, so these risks can be minimized based on current evidence-based medicine. To minimize the risk of complications, the surgeon should take an active role in each step of the patient's care beginning with the history and physical examination, obtaining the correct preoperative labs, and continuing through positioning, draping, and prepping before making an incision.
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Affiliation(s)
- Wendell W Cole
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
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40
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Rana AJ, Yates AJ, Springer BD, Huddleston JI, Iorio R. Hip and Knee Arthroplasty Alternative Payment Model Successes and Challenges. Arthroplast Today 2022; 13:154-156. [PMID: 35097170 PMCID: PMC8783115 DOI: 10.1016/j.artd.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/27/2021] [Indexed: 11/10/2022] Open
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Kulshrestha V, Sood M, Kumar S, Sood N, Kumar P, Padhi PP. Does Risk Mitigation Reduce 90-Day Complications in Patients Undergoing Total Knee Arthroplasty? A Cohort Study. Clin Orthop Surg 2022; 14:56-68. [PMID: 35251542 PMCID: PMC8858904 DOI: 10.4055/cios20234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 11/08/2022] Open
Abstract
Background With ever-increasing demand for total knee arthroplasty (TKA), most healthcare systems around the world are concerned about its socioeconomic burden. Most centers have universally adopted well-defined clinical care pathways to minimize adverse outcomes, maximize volume, and limit costs. However, there are no prospective comparative trials reporting benefits of these risk mitigation (RM) strategies. Methods This is a prospective cohort study comparing post-TKA 90-day complications between patients undergoing RM before surgery and those following a standard protocol (SP). In the RM group, we used a 20-point checklist to screen for modifiable risk factors and evaluate the need for optimizing non-modifiable comorbidities. Only when optimization goals were achieved, patients were offered TKA. Results TKA was performed in 811 patients in the SP group and in 829 in the RM group, 40% of which were simultaneous bilateral TKA. In both groups, hypertension was the most prevalent comorbidity (48%), followed by diabetes (20%). A total of 43 (5.3%) procedure-related complications were seen over the 90-day postoperative period in the SP group, which was significantly greater than 26 (3.1%) seen in the RM group (p = 0.039). The commonest complication was pulmonary thromboembolic, 6 in each group. Blood transfusion rate was higher in the SP group (6%) than in the RM group (< 1%). Conclusions Screening and RM can reduce 90-day complications in patients undergoing TKA.
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Affiliation(s)
- Vikas Kulshrestha
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
| | - Munish Sood
- Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Chandimandir, Chandigarh, India
| | - Santhosh Kumar
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
| | - Nikhil Sood
- Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Chandimandir, Chandigarh, India
| | - Pradeep Kumar
- Department of Orthopaedics and Major Rehabilitation Center, Air Force Hospital Kanpur, Kanpur, India
| | - Prashanth P Padhi
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
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Pehlivan E, Palalı İ, Atan S, Turan D, Çınarka H, Çetinkaya E. The effectiveness of POST-DISCHARGE telerehabilitation practices in COVID-19 patients: Tele-COVID study-randomized controlled trial. Ann Thorac Med 2022; 17:110-117. [PMID: 35651892 PMCID: PMC9150661 DOI: 10.4103/atm.atm_543_21] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/08/2022] [Indexed: 11/04/2022] Open
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43
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O'Connor MI. Equity360: Gender, Race, and Ethnicity: Our "Best Hospitals" Rank Poorly in Health Equity. Clin Orthop Relat Res 2021; 479:2366-2368. [PMID: 34559694 PMCID: PMC8509955 DOI: 10.1097/corr.0000000000001990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 01/31/2023]
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Day case unicompartmental knee replacement: An update of the Torbay experience. Knee 2021; 32:166-172. [PMID: 34500429 DOI: 10.1016/j.knee.2021.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/04/2021] [Accepted: 08/13/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hospitals throughout the United Kingdom face significant challenges in regards to inpatient bed capacity, leading to growing interest in day case arthroplasty. Day case Unicompartmental Knee Replacement (UKR) has been offered within our unit since 2010, with successive evaluations of pathway outcomes performed in 2011 and 2015. Since then, our day case UKR pathway has expanded. This study aims to evaluate the safety, efficiency and patient satisfaction with this expanded pathway. METHODS Data was prospectively collected for all patients undergoing a UKR between January 2017 and August 2019. Data collected included the pathway planned, date of admission, date of discharge and re-admissions to hospital within 30 days of surgery. Patient satisfaction was evaluated via a follow-up questionnaire. RESULTS 109 patients underwent a UKR between January 2017 and August 2019. 83 patients (76%) were planned through the day case pathway. 63 patients were successfully discharged on the day of surgery. One day case pathway and two inpatient pathway patients were re-admitted within 30 days of surgery with medical conditions. A high level of patient satisfaction with our day case pathway was identified. CONCLUSION UKR with planned discharge on the day of surgery is possible for a large proportion of patients provided that robust pathway and protocol design is undertaken. Following 10 years' experience, our day case UKR pathway has increasingly become the default for the majority of our patients. We report high patient satisfaction and low 30-day re-admission rates. However, 100% success rate for day of surgery discharge remains challenging.
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Doman DM, Young AM, Buller LT, Deckard ER, Meneghini RM. Comparison of Surgical Site Complications With Negative Pressure Wound Therapy vs Silver Impregnated Dressing in High-Risk Total Knee Arthroplasty Patients: A Matched Cohort Study. J Arthroplasty 2021; 36:3437-3442. [PMID: 34140207 DOI: 10.1016/j.arth.2021.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Closed incision negative pressure wound therapy (ciNPWT) may reduce surgical site complications following total joint arthroplasty. Although unlikely necessary for all patients, the criteria for utilizing ciNPWT in primary total knee arthroplasty (TKA) remain poorly defined. This study's purpose was to compare the incidence of incisional wound complications, non-incisional complications (ie, dressing reactions), reoperations, and periprosthetic joint infections (PJIs) among a group of high-risk primary TKA patients treated with ciNPWT vs an occlusive silver impregnated dressing. METHODS One hundred thirty high-risk primary TKA patients treated with ciNPWT were 1:1 propensity matched and compared to a historical control group treated with an occlusive silver impregnated dressing. High-risk criteria included the following: active tobacco use, diabetes mellitus, body mass index >35 kg/m2, autoimmune disease, chronic kidney disease, Staphylococcus aureus nasal colonization, and non-aspirin anticoagulation. RESULTS Age, gender, and risk factor profile were comparable between cohorts. The ciNPWT cohort had significantly fewer incisional wound complications (6.9% vs 16.2%; P = .031) and significantly more non-incisional complications (16.9% vs 1.5%; P < .001). No dressing reactions required clinical intervention. There were no differences in reoperations or periprosthetic joint infections (P = 1.000). In multivariate analysis, occlusive silver impregnated dressings (odds ratio 2.9, 95% confidence interval 1.3-6.8, P = .012) and non-aspirin anticoagulation (odds ratio 2.5, 95% confidence interval 1.1-5.6, P = .028) were associated with the development of incisional wound complications. CONCLUSION Among high-risk patients undergoing primary TKA, ciNPWT decreased incisional wound complications when compared to occlusive silver impregnated dressings, particularly among those receiving non-aspirin anticoagulation. Although an increase in dressing reactions was observed, the clinical impact was minimal.
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Affiliation(s)
- David M Doman
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA
| | | | - Leonard T Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Evan R Deckard
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Dlott CC, Pei X, Ittner JL, Lefar SL, O'Connor MI. Intersectionality of Net Worth and Race Relative to Utilization of Total Hip and Knee Arthroplasty. J Arthroplasty 2021; 36:3060-3066.e1. [PMID: 34099350 DOI: 10.1016/j.arth.2021.04.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/18/2021] [Accepted: 04/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although the number of total hip arthroplasty and total knee arthroplasty (THA and TKA) increases, individuals of color continue to be less likely to undergo these procedures. Socioeconomic status may be a key influencer of THA and TKA utilization and outcomes. We explore the influence of net worth and race on THA and TKA utilization and outcomes of length of stay and readmissions using a large patient database. METHODS The StrataSphere data set, an aggregation of 49 health systems representing 209 hospitals, was used for primary THA and TKA procedures performed in the calendar year 2019. Net worth was determined from Market Vue Partners' data sources. Statistical analyses were performed to investigate relationships between net worth and patients undergoing THA or TKA. RESULTS When comparing our overall patient cohorts with the US population using Census data, we found differences in the utilization pattern indicated by index ratios most clearly in the lowest net worth categories. In the <$10K net worth category, THA and TKA index ratios were 0.51 and 0.54, respectively. In addition, we found that patients in the $100-250 and $250-500K net worth categories had increased utilization of both THA (index ratios of 1.39, 1.53) and TKA (index ratios of 1.45, 1.47) surgeries. CONCLUSION Net worth is a strong driver of disparities in utilization of THA and TKA with lower utilization of these surgeries in patients with net worth <$10K and increased utilization in patients with net worth from $100-250 and $250-500K.
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Affiliation(s)
| | - Xun Pei
- Strata Decision Technology, Chicago, IL
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Meena OP, Kalra P, Shukla A, Naik AK, Iyengar KP, Jain VK. Is performing joint arthroplasty surgery during the COVID-19 pandemic safe?: A retrospective, cohort analysis from a tertiary centre in NCR, Delhi, India. J Clin Orthop Trauma 2021; 21:101512. [PMID: 34312579 PMCID: PMC8295060 DOI: 10.1016/j.jcot.2021.101512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 07/16/2021] [Accepted: 07/18/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Resuming joint replacement arthroplasty amidst the COVID-19 pandemic and lockdown has come with various challenges that had to be dealt with utmost caution. Patients with severe arthritis experiencing a state of intolerable pain, could not be left unaddressed. Guidelines published by surgical associations, collaborative surgical author groups including public health organisations had to be modified to suit the Indian scenario and obtain optimal functional outcomes in these patients. METHODS A retrospective cohort analysis of 147 patients who underwent arthroplasty during the pandemic (March 2020 to April 2021), for either primary or secondary arthritis, was performed. We assess the efficacy and safety of the newly established Institutional surgical peri-operative protocol at our tertiary care centre in the National Capital Region, India in response to COVID-19 guidelines. The primary outcome measures appraised was 30-day mortality and the secondary outcome measures included length of stay, peri-operative complications and COVID-19 infection. RESULT The most common indication for arthroplasty during the pandemic was neglected trauma. One patient died, due to myocardial infarction during the follow-up period. About 67% of patients were discharged to their usual residence within 7 days of admission. Two patients tested positive for COVID-19 postoperatively, but none required Intensive Care Unit admission. CONCLUSION Joint replacement arthroplasty can be undertaken safely with diligent patient selection, application of a stringent COVID appropriate behaviour and a 'ring-fenced' peri-operative pathway.
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Affiliation(s)
- Om Prakash Meena
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - Pulkit Kalra
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - Ajay Shukla
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - Ananta Kumar Naik
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - Karthikeyan P. Iyengar
- Trauma and Orthopaedic Surgeon, Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK
| | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India,Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical sciences Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India.
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Hauer G, Smolle M, Zaussinger S, Friesenbichler J, Leithner A, Maurer-Ertl W. Short-stem total hip arthroplasty is not associated with an earlier return to work compared to a straight-stem design. Sci Rep 2021; 11:4968. [PMID: 33654124 PMCID: PMC7925530 DOI: 10.1038/s41598-021-82805-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 01/25/2021] [Indexed: 11/09/2022] Open
Abstract
Return to work (RTW) has been specifically identified as a high priority in patients undergoing total hip arthroplasty (THA). This investigation sought to assess the effect of the stem design on patients' RTW. Secondly, the study aimed to identify risk factors that lead to a delayed RTW. Questionnaires inquiring about RTW, employment history, educational level, type of work, physical demands and joint awareness were administered by post. Further data were collected from patients' hospital records. 176 patients who underwent THA using a short-stem and 97 patients using a straight-stem design were compared. The median return to work time was 10 weeks [IQR 7-14 weeks], with no significant difference between the two groups (short stems vs. straight stems; 10 [IQR 7-14] vs. 11 [7.5-13.5] weeks; p = 0.693). In the multivariate linear regression analysis, self-employment vs. employee (p = 0.001), dimension of preoperative workload (p = 0.001), preoperative sick leave (p < 0.001), and hospital length of stay (LOS) (p < 0.001) independently affected the period until work was resumed. The Forgotten-Joint-Score-12 showed no significant difference between the two groups. The data show that the majority of THA patients can expect to resume work and stem design has no impact on RTW. Employees with preoperative sick leave, prolonged hospital LOS and low workload are at higher risk for a delayed RTW.
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Affiliation(s)
- Georg Hauer
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Maria Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Sabrina Zaussinger
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Joerg Friesenbichler
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Werner Maurer-Ertl
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
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Preoperative risk factors for postoperative cardiac arrest following primary total hip and knee arthroplasty: A large database study. J Clin Orthop Trauma 2021; 16:244-248. [PMID: 33717961 PMCID: PMC7920110 DOI: 10.1016/j.jcot.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Cardiac arrest (CA) has been identified as a potential complication following Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA). This retrospective, case-controlled study aims to identify risk factors in order to improve the management of patients undergoing THA or TKA with known preoperative comorbidities. METHODS CPT codes were used to investigate the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for patients who underwent THA or TKA from 2010 to 2017. Patients were classified as having cardiac arrest (CA) by the NSQIP guidelines. Patient samples with all possible covariates were included for the multivariate logistic regression analysis and assessed for independent association. RESULTS Patients receiving perioperative transfusion, experiencing dyspnea with moderate exertion, dyspnea at rest, patients currently on dialysis, and patients aged ≥72 are all independently associated with increased rates of cardiac arrest (CA) following THA. Patients receiving perioperative transfusion, patients with anemia, bleeding disorders, dyspnea with moderate exertion, cardiac comorbidities, pulmonary comorbidities, and patients aged ≥73 are all associated with increased rates of cardiac arrest (CA) following TKA. CONCLUSION Patients with the identified risk factors are at a greater risk of suffering cardiac arrest within 30 days following THA and TKA. It is imperative that we recognize which risk factors may precipitate CA in THA and TKA recipients so that prophylactic management can be employed. Furthermore, management guidelines should be updated for patients at high risk of CA following THA and TKA to prevent this complication.
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