Health insurance database for post-discharge surveillance of surgical site infection following arthroplasty

Factors associated with urinary diversion and fatality of hospitalised acute pyelonephritis patients in France: a national cross-sectional study (FUrTIHF-2)

Acute pyelonephritis (AP) epidemiology has been sparsely described. This study aimed to describe the evolution of AP patients hospitalised in France and identify the factors associated with urinary diversion and fatality, in a cross-sectional study over the 2014-2019 period. Adult patients hospitalised for AP were selected by algorithms of ICD-10 codes (PPV 90.1%) and urinary diversion procedure codes (PPV 100%). 527,671 AP patients were included (76.5% female: mean age 66.1, 48.0% Escherichia coli), with 5.9% of hospital deaths. In 2019, the AP incidence was 19.2/10,000, slightly increasing over the period (17.3/10,000 in 2014). 69,313 urinary diversions (13.1%) were performed (fatality rate 6.7%), mainly in males, increasing over the period (11.7% to 14.9%). Urolithiasis (OR [95% CI] =33.1 [32.3-34.0]), sepsis (1.73 [1.69-1.77]) and a Charlson index ≥3 (1.32 [1.29-1.35]) were significantly associated with urinary diversion, whereas E. coli (0.75 [0.74-0.77]) was less likely associated. The same factors were significantly associated with fatality, plus old age and cancer (2.38 [2.32-2.45]). This nationwide study showed an increase in urolithiasis and identified, for the first time, factors associated with urinary diversion in AP along with death risk factors, which may aid urologists in clinical decision-making.

A systematic review of cost and well-being in hip and knee replacements surgical site infections

This systematic review examined peer-reviewed literature published from 2010 to 2020 to investigate the health care system costs, hidden out-of-pocket expenses and quality of life impact of surgical site infections (SSIs) and to develop an overall summary of the burden they place on patients. SSI can significantly impact patients' treatment experience and quality of life. Understanding patients' SSI-related burden may assist in developing more effective strategies aimed at lessening the effects of SSI in financial and well-being consequences. Peer-reviewed articles on adult populations (over 18 years old) in orthopaedic elective hip and knee surgeries published from 2010 to 2020 were considered. Only publications in English and studies conducted in high-income countries were eligible for inclusion. A search strategy based on the MESH term and the CINAHL terms classification was developed. Five databases (Scopus, EMBASE, CINAHL, Medline, Web of Science) were searched for relevant sources. Reviewers categorised and uploaded identified citations to Covidence and EndNoteX9. Reviewers will assess article titles, abstracts and the full text for compliance with the inclusion criteria. Ongoing discussions between reviewers resolved disagreements at each selection process stage. The final scoping review reported the citation inclusion process and presented search results in a PRISMA flow diagram. Four main themes were extracted from a thematic analysis of included studies (N = 30): Hospital costing (n = 21); Societal perspective of health system costing (n = 2); Patients and societal well-being (n = 6) and Epidemiological database and surveillance (n = 22). This systematic review has synthesised a range of themes associated with the overall incidence and impact of SSI that can inform decision making for policymakers. Further analysis is required to understand the burden on SSI patients.

Validation of the first computerized indicator for orthopaedic surgical site infections in France: ISO-ORTHO

BACKGROUND

The French national authority for health (HAS) develops in-hospital indicators for improving quality of care, safety and patient outcome. Since 2017, it has developed a measurement of surgical site infections (SSI) after total hip or knee arthroplasty (TH/KA) by using a computerized indicator, called ISO-ORTHO, based on a hospital discharge database (HDD) algorithm. The aim of the study was to assess the performance of this new indicator .

METHODS

The ISO-ORTHO performance was estimated via its positive predictive value (PPV) among adult patients having undergone a TH/KA between January 1st and September 30th 2018, based on the orthopaedic procedure codes. Patients at very high risk of SSI and/or with SSI not related to the in-hospital care were excluded. SSI were detected from the date of admission up to 90 days after the TH/KA using the ISO-ORTHO algorithm, based on 15 combinations of ICD-10 and procedure codes. Its PPV was estimated by a chart review in volunteer healthcare organisations (HCO).

RESULTS

Over the study period, 777 HCO including 143,227 TH/KA stays were selected, providing 1,279 SSI according to the ISO-ORTHO indicator. The 90-day SSI rate was 0.89 per 100 TH/KA stays (0.98% for THA and 0.80% for TKA). Among the 448 HCO with at least 1 SSI, 250 HCO participated in reviewing 725 SSI charts; 665 were confirmed, giving a PPV of 90.3% [88.2-92.5%], 89.9% [87.1-92.8%] in THA and 90.9% [87.7-94.2%] in TKA.

CONCLUSIONS

The PPV of ISO-ORTHO over 90% confirms its validity for any use according to the HAS method. ISO-ORTHO and detailed information were provided in 2020 to HCO and used for quality assessment and in-hospital risk management.

The Effect of a Discharge Disposition Algorithm on Patient Outcomes and Satisfaction

Total joint arthroplasties are one of the most common procedures performed in the United States. As changes have occurred in the surgical techniques of these procedures, postoperative recovery time has decreased and patients have been able to safely transition to home rather than a post-acute care facility. The demand for total joint arthroplasty (TJA) is expected to grow 44% as the prevalence of lower extremity osteoarthritis continues to rise (Sher et al., 2017) because of an aging baby boomer population. In the next 20 years, it is expected that the demand for total hip arthroplasty will grow by 174% and demand for total knee arthroplasty will grow by as much as 670% (Napier et al., 2013). An area with high variability in the postoperative period is in postdischarge rehabilitation. Post-acute inpatient care can account for up to 36% of the bundled costs of a TJA. There is a lack of evidence that patients recover better or have decreased complications by transitioning to an inpatient rehabilitation setting compared with transitioning to home. The aims of this literature search were to (a) identify the safest discharge disposition for patients following TJA; (b) determine the rate of complications and readmissions among those discharged to skilled nursing facility, inpatient rehabilitation unit, and home; and (c) explore how specified care pathways affect patient expectations and outcomes. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, ProQuest, and Cochrane were searched using the following key terms: discharge disposition, total joint arthroplasty, joint replacement, hip arthroplasty, knee arthroplasty, care pathway, discharge outcomes and readmissions, discharge protocols, and discharge algorithms. Five key themes emerged. Patients with significant comorbidities may require longer length of stay in the hospital or potentially discharge to a facility, discharge to facility associated with high rate of complications, setting patient expectations increases likelihood of discharge home, discharge to inpatient facilities does not improve outcomes, and discharge to any post-acute care facility is more expensive than discharge to home. This review identified themes in postoperative care of TJA patients that can be utilized to create a discharge disposition algorithm using best practices to stratify patients into the appropriate discharge disposition while setting appropriate expectations for patients undergoing these procedures to ensure high levels of patient satisfaction following these procedures.

Epidemiology of complex bone and joint infections in France using a national registry: The CRIOAc network

OBJECTIVES

In France, a network of reference centers for bone and joint infections (BJI) was created in 2008, focused on the management of complex BJI (previous failure, difficult-to-treat microorganisms, heavy comorbidities or surgical procedures). A national registry was implemented from 2012, collecting decisions advised in periodic multidisciplinary meetings. We present here an epidemiological overview.

METHODS

All consecutive adult patients presented from 2014 to 2019 in 23/30 reference centers were included in this cohort. Characteristics of patients, BJI, and medico-surgical management advice were described.

RESULTS

27,483 individual patients were included, corresponding to 28,365 distinct infectious episodes, which 17,328 were complex. Median age was 65 years, with 62% of men, 1/3 patients presented more than 2 comorbidities. Prosthetic joint infections (PJI) represented 42% of all BJIs (11,812 episodes). Staphylococcus aureus, coagulase-negative staphylococci and polymicrobial PJI represented 26%, 25% and 16% respectively. DAIR (debridement, antibiotics and implant retention) was proposed for 3,157 (27%), whereas one-stage and two-stage revision for 3,683 (31%) and 1,764 (15%). An antibiotic treatment was advised in 10,493 episodes (87%), with combination therapy in 88%.

CONCLUSION

This national network allows an optimized management of complex BJIs. Its cohort is a unique opportunity to draw up a detailed epidemiological picture and to follow the trends of these infrequent infections.

Key features of bone and joint infections following the implementation of reference centers in France

OBJECTIVES

French reference centers for bone and joint infections (BJI) were implemented from 2009 onwards to improve the management of complex BJIs. This study compared BJI burden before and after the implementation of these reference centers.

PATIENTS AND METHODS

BJI hospital stays were selected from the 2008 and 2013 national hospital discharge database using a validated algorithm, adding the new complex BJI code created in 2011. Epidemiology and economic burden were assessed.

RESULTS

BJI prevalence increased in 2013 (70 vs. 54/100,000 in 2008). Characteristics of BJI remained similar between 2008 and 2013: septic arthritis (50%), increasing prevalence with age and sex, case fatality 5%, mean length of stay 17.5 days, rehospitalization 20%. However, device-associated BJIs increased (34 vs. 26%) as well as costs (€421 million vs. €259 in 2008). Similar device-associated BJI characteristics between 2008 and 2013 were: septic arthritis (70%), case fatality (3%), but with more hospitalizations in reference centers (34 vs. 30%) and a higher cost per stay. Among the 7% of coded complex BJIs, the mean length of stay was 22.2 days and mean cost was €11,960.

CONCLUSIONS

BJI prevalence highly increased in France. Complex BJI prevalence assessment is complicated by the absence of clinical consensus and probable undercoding. A validation of clinical case definition of complex BJI is required.

The '6W' multidimensional model of care trajectories for patients with chronic ambulatory care sensitive conditions and hospital readmissions

OBJECTIVES

To synthesize concepts and approaches related to the analysis of patterns or processes of care and patient's outcomes into a comprehensive model of care trajectories, focusing on hospital readmissions for patients with chronic ambulatory care sensitive conditions (ACSCs).

STUDY DESIGN

Narrative literature review.

METHODS

Published studies between January 2000 and November 2017, using the concepts of 'continuity', 'pathway', 'episode', and 'trajectory', and focused on readmissions and chronic ACSCs, were collected in electronic databases. Qualitative content analysis was performed with emphasis on key constituents to build a comprehensive model.

RESULTS

Specific common constituents are shared by the concepts reviewed: they focus on the patient, aim to measure and improve outcomes, follow specific periods of time and consider other factors related to care providers, care units, care settings, and treatments. Using these common denominators, the comprehensive '6W' multidimensional model of care trajectories was created. Considering patients' attributes and their chronic ACSCs illness course ('who' and 'why' dimensions), this model reflects their patterns of health care use across care providers ('which'), care units ('where'), and treatments ('what'), at specific periods of time ('when').

CONCLUSIONS

The '6W' model of care trajectories could provide valuable information on 'missed opportunities' to reduce readmission rates and improve quality of both ambulatory and inpatient care.

[The use of administrative health databases in infectious disease epidemiology and public health]

BACKGROUND

The public health burden resulting from infectious diseases requires efforts in surveillance and evaluation of health care. The use of administrative health databases (AHD) and in particular the French national health insurance database (SNIIRAM) is an opportunity to improve knowledge in this field. The SNIIRAM data network (REDSIAM) workshop dedicated to infectious diseases conducted a narrative literature review of studies using French AHD. From the results, benefits and limits of these new tools in the field of infectious diseases are presented.

METHODS

Publications identified by the members of the workgroup were collected using an analytical framework that documented the pathology of interest, the aim of the study, the goal of the developed algorithm, the kind of data, the study period, and the presence of an evaluation or a discussion of the performance of the performed algorithm.

RESULTS

Fifty-five articles were identified. A majority focused on the field of vaccination coverage and joint infections. Excluding vaccine coverage field, the aim of 28 studies was epidemiological surveillance. Twenty-six studies used hospital databases exclusively, 18 used ambulatory databases exclusively and 4 used both. Validation or discussion of the performed algorithm was present in 18 studies.

CONCLUSIONS

The literature review confirmed the interest of the French AHD in the infectious diseases field. The AHD are additional tools of the existing surveillance systems and their use will probably be more frequent in the coming years given their advantage and reliability. However, incoming users need to be assisted. Thus, the workgroup will contribute to a reasonable use of AHD and support future developments.