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Mayfield CK, Abu-Zahra MS, Bolia IK, Kotlier JL, Lin EH, Gamradt SC, Weber AE, Liu JN, Petrigliano FA. Preoperative Mental Health Disorders Affect Opioid Consumption and Perioperative Complications After Total Shoulder Arthroplasty. Orthopedics 2024:1-8. [PMID: 39312745 DOI: 10.3928/01477447-20240918-01] [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: 09/25/2024]
Abstract
BACKGROUND Limited evidence exists regarding the influence of mental health disorders (MHDs) on opioid use and complications after total shoulder arthroplasty (TSA). We aimed to identify the prevalence of common MHDs among patients undergoing anatomic TSA (aTSA) and reverse TSA (rTSA). MATERIALS AND METHODS The Premier Healthcare Database was queried for patients undergoing primary aTSA and rTSA from 2016 to 2020. International Classification of Diseases, Tenth Revision, diagnosis codes were used to identify MHDs. Primary outcomes included the prevalence of MHDs, perioperative opioid consumption, and 90-day risk of postoperative complications, revision, and readmission. Bivariate and multivariate regression analyses were performed to assess 90-day risk of primary endpoints while controlling for potential confounders. Statistical significance was defined as P<.05. RESULTS From 2016 to 2020, 49,997 of 144,725 (34.55%) patients undergoing primary TSA had at least one diagnosed MHD. The most prevalent were depression (17.03%), anxiety (16.75%), and substance use disorder (10.20%). Patients with a MHD had higher mean hospital costs ($75,984±$43,129 vs $73,316±$39,046, P<.0001), longer mean length of stay (1.95±2.25 days vs 1.61±1.51 days, P<.0001), and higher mean total postoperative opioid use (72.00±231.55 morphine milligram equivalents [MMEs] vs 59.32±127.31 MMEs, P<.0001). Periprosthetic fractures (odds ratio, 1.20; P=.041), dislocation (odds ratio, 1.12; P=.042), and 90-day readmission rates (odds ratio, 1.26; P<.001) were significantly higher among patients with a MHD. CONCLUSION This study found that MHDs are associated with significantly increased perioperative opioid consumption, medical and surgical complication rates, and risk of readmission after TSA. Recognition and optimization of MHDs is critical to minimizing complications and opioid consumption after TSA. [Orthopedics. 202x;4x(x):xx-xx.].
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Daher M, Boufadel P, Lopez R, Chalhoub R, Fares MY, Abboud JA. Beyond the joint: Exploring the interplay between mental health and shoulder arthroplasty outcomes. J Orthop 2024; 52:1-5. [PMID: 38404698 PMCID: PMC10881441 DOI: 10.1016/j.jor.2024.02.005] [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: 02/01/2024] [Accepted: 02/09/2024] [Indexed: 02/27/2024] Open
Abstract
Considering the fact that mental health illnesses increase with age, and that shoulder arthroplasty procedures are often indicated in the older population, exploring the relationship between mental health and shoulder arthroplasty outcomes can have pivotal implications for shoulder surgeons and patients worldwide. The literature has shown that patients with poor mental health report lower patient-reported outcomes, higher peri-operative complications (such as anemia, infection, delirium, and others), lengthier hospital stays, and higher readmission rates than the normal patient. Employing a holistic approach when managing shoulder arthroplasty patients is necessary for optimizing outcomes and setting up recovery expectations.
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Affiliation(s)
| | | | - Ryan Lopez
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Shimizu MR, Lin-Wei Chen T, Buddhiraju A, Bacevich B, Huang Z, Kwon YM. Neighborhood socioeconomic disadvantages associated with prolonged length of stay and non-home discharge following revision total hip and knee joint arthroplasty. J Clin Orthop Trauma 2024; 52:102428. [PMID: 38766389 PMCID: PMC11097079 DOI: 10.1016/j.jcot.2024.102428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024] Open
Abstract
Background Discharge disposition and length of stay (LOS) are widely recognized markers of healthcare utilization patterns of total hip and knee joint arthroplasty (TJA). These markers are commonly associated with increased postoperative complications, patient dissatisfaction, and higher costs. Area deprivation index (ADI) has been validated as a composite metric of neighborhood-level disadvantage. This study aims to determine the potential association between ADI and discharge disposition or extended LOS following revision TJA. Methods This study conducted a retrospective analysis of a consecutive series of revision hip and knee TJA patients from a single tertiary institution. Univariate and multivariate regression analysis was used to determine the association between ADI and discharge disposition or LOS, adjusting for patient demographics and comorbidities. Results 1047 consecutive revision TJA patients were identified across 463 different neighborhoods. 193 (18.4 %) had an extended LOS, and 334 (31.9 %) were discharged to non-home facilities. Compared with Q1 (least deprived cohort), Q2 (odds ratio [OR] = 1.63; p = 0.030) and Q4 (most deprived cohort: OR = 2.04; p = 0.002) cohorts demonstrated higher odds of non-home discharge. Patients in the highest ADI quartile (most deprived cohort) were associated with increased odds of prolonged LOS following revision TJA compared to those in the lowest ADI quartile (OR = 2.63; p < 0.001). Conclusion This study suggests that higher levels of neighborhood-level disadvantage may be associated with higher odds of non-home discharge and prolonged LOS following revision TJA. Development of interventions based on the area deprivation index may improve discharge planning and reduce unnecessary non-home discharges in patients living in areas of socioeconomic deprivation.
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Affiliation(s)
- Michelle Riyo Shimizu
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tony Lin-Wei Chen
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anirudh Buddhiraju
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Blake Bacevich
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ziwei Huang
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Young-Min Kwon
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Jennewine BR, Throckmorton TW, Pierce AS, Miller AH, Azar AT, Sharp CD, Azar FM, Bernholt DL, Brolin TJ. Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update. J Shoulder Elbow Surg 2024; 33:900-907. [PMID: 37625693 DOI: 10.1016/j.jse.2023.07.018] [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: 04/03/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution. METHODS A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations. RESULTS A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes. CONCLUSIONS There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.
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Affiliation(s)
- Brenton R Jennewine
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Andrew S Pierce
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Andrew H Miller
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adrian T Azar
- College of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
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Pearson ZC, Ahiarakwe U, Bahoravitch TJ, Schmerler J, Harris AB, Thakkar SC, Best MJ, Srikumaran U. Social Determinants of Health Disparities Increase the Rate of Complications After Total Knee Arthroplasty. J Arthroplasty 2023; 38:2531-2536.e3. [PMID: 37659681 DOI: 10.1016/j.arth.2023.08.077] [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: 03/27/2023] [Revised: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Few studies have investigated whether social determinants of health disparities (SDHD), which include economic, social, education, health care, and environmental factors, identified through International Classification of Diseases (ICD) codes are associated with increased odds for poor health outcomes. We aimed to investigate the association between SDHD, identified through this novel methodology, as well as postoperative complications following total knee arthroplasty (TKA). METHODS Using a national insurance claims database, a retrospective cohort analysis was performed. Patients were selected using Current Procedural Terminology and ICD codes for primary TKA between 2010 and 2019. Patients were stratified into 2 groups using ICD codes, those who had SDHD and those who did not, and propensity matched 1:1 for age, sex, a comorbidity score, and other comorbidities. After matching, 207,844 patients were included, with 103,922 patients in each cohort. Odds ratios (ORs) for 90-day medical and 2-year surgical complications were obtained using multivariable logistical regressions. RESULTS In patients who have SDHD, multivariable analysis demonstrated higher odds of readmission (OR): 1.12; P = .013) and major and minor medical complications (OR: 2.09; P < .001) within 90-days as well as higher odds of revision surgery (OR: 1.77; P < .001) and periprosthetic joint infection (OR: 1.30; P < .001) within 2-years. CONCLUSION The SDHD are an independent risk factor for revision surgery and periprosthetic joint infection after TKA. In addition, SDHD is also an independent risk factor for all-cause hospital readmissions and both minor and major complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Zachary C Pearson
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Uzoma Ahiarakwe
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Tyler J Bahoravitch
- The School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia
| | - Jessica Schmerler
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Savyasachi C Thakkar
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Mathew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
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Lee BG, Lee D, Koh JH. Relationship between the preoperative grip strength and postoperative shoulder strength of patients treated via reverse shoulder arthroplasty. J Shoulder Elbow Surg 2023; 32:2430-2435. [PMID: 37516347 DOI: 10.1016/j.jse.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/11/2023] [Accepted: 06/24/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Systemic disorders including diabetes mellitus, obesity, and depression affect the outcomes of reverse shoulder arthroplasty (RSA). Sarcopenia (a general skeletal muscle disorder) is common in elderly people, but its effect on patients after RSA is not clear. We hypothesized that the preoperative sarcopenia indices of grip strength and general skeletal muscle mass would correlate with the clinical outcomes of RSA. METHODS Grip strength and general skeletal muscle mass were measured in patients scheduled (between 2016 and 2021) for primary RSA to treat cuff tear arthropathy, an unrepairable cuff tear, or osteoarthritis with a large cuff tear. Before surgery, grip strength was measured using a hydraulic dynamometer and general skeletal muscle mass was calculated from the appendicular relative skeletal muscle mass index (aRSMI) using dual-energy X-ray absorptiometry. In all, 58 patients were included; the minimal follow-up duration was 12 months. The postoperative clinical results (pain, active range of motion, shoulder strength, and functional scores) were evaluated during scheduled outpatient visits. We calculated correlations between the preoperative sarcopenia indices, and the clinical results at the final follow-up. RESULTS The mean preoperative grip strength and aRSMI were 21.6 ± 4.0 kg and 5.98 ± 0.84 kg/m2 in females and 30.6 ± 7.5 kg and 7.21 ± 0.94 kg/m2 in males, respectively; the grip strength and aRSMI were not associated with each other (P = .083). Ten females (25%) and 10 males (56%) met the criteria for sarcopenia. The postoperative abduction shoulder strength and Constant-Murley shoulder score increased significantly with higher preoperative grip strength (R = 0.420 and P = .001; and R = 0.497 and P < .001, respectively) and the American Shoulder and Elbow Surgeons score was related to the preoperative aRSMI (R = 0.320, P = .039). CONCLUSIONS The shoulder strength and functional score after RSA correlated positively with the preoperative grip strength. Measuring grip strength before RSA allows the surgeon to predict shoulder strength after RSA.
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Affiliation(s)
- Bong Gun Lee
- Department of Orthopaedic Surgery, Hanyang University, School of Medicine, Seoul, Republic of Korea
| | - DooHyung Lee
- Department of Orthopaedic Surgery, Ajou University, School of Medicine, Suwon, Republic of Korea.
| | - Jeong-Hyun Koh
- Department of Orthopaedic Surgery, Ajou University, School of Medicine, Suwon, Republic of Korea
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7
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Keller DM, Saad BN, Hong IS, Gencarelli P, Tang A, Jankowski JM, Liporace FA, Yoon RS. Comparison of Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Proximal Humerus Fractures Versus Rotator Cuff Arthropathy. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202310000-00006. [PMID: 37856701 PMCID: PMC10589608 DOI: 10.5435/jaaosglobal-d-23-00160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/01/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Indications for reverse total shoulder arthroplasty (rTSA) has expanded to encompass complex proximal humerus fractures (PHFs) in recent years. The purpose of this study was to report and assess whether PHF patients treated with rTSA could achieve similar functional outcomes and short-term survivorship to patients who underwent rTSA for rotator cuff arthropathy (RTCA). METHODS All consecutive patients with a preoperative diagnosis of PHF or RTCA, 18 years or older, treated with rTSA at a single academic institution between 2018 and 2020 with a minimum 2-year follow-up were retrospectively reviewed. Primary outcomes were survivorship defined as revision surgery or implant failure analyzed using the Kaplan-Meier survival curve, and functional outcomes, which included Quick Disabilities of the Arm, Shoulder, and Hand, and range of motion (ROM) were compared at multiple follow-up time points up to 2 years. Secondary outcomes were patient demographics, comorbidities, surgical data, length of hospital stay, and discharge disposition. RESULTS A total of 48 patients were included: 21 patients (44%) were diagnosed with PHF and 27 patients (56%) had RTCA. The Kaplan-Meier survival rate estimates at 3 years were 90.5% in the PHF group and 85.2% in the RTCA group. No differences in revision surgery rates between the two groups (P = 0.68) or survivorship (P = 0.63) were found. ROM was significantly lower at subsequent follow-up time points in multiple planes (P < 0.05). A greater proportion of patients in the PHF group received cement for humeral implant fixation compared with the RTCA group (48% versus 7%, P = 0.002). The mean length of hospital stay was longer in PHF patients compared with RTCA patients (2.9 ± 3.8 days versus 1.6 ± 1.8 days, P = 0.13), and a significantly lower proportion of PHF patients were discharged home (67% versus 96%, P = 0.015). CONCLUSION The rTSA implant survivorship at 3 years for both PHF and RTCA patients show comparable results. At the 2-year follow-up, RTCA patients treated with rTSA were found to have better ROM compared with PHF patients.
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Affiliation(s)
- David M. Keller
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center–RWJBarnabas Health, Livingston, NJ/Jersey City, NJ
| | - Bishoy N. Saad
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center–RWJBarnabas Health, Livingston, NJ/Jersey City, NJ
| | - Ian S. Hong
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center–RWJBarnabas Health, Livingston, NJ/Jersey City, NJ
| | - Pasquale Gencarelli
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center–RWJBarnabas Health, Livingston, NJ/Jersey City, NJ
| | - Alex Tang
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center–RWJBarnabas Health, Livingston, NJ/Jersey City, NJ
| | - Jaclyn M. Jankowski
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center–RWJBarnabas Health, Livingston, NJ/Jersey City, NJ
| | - Frank A. Liporace
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center–RWJBarnabas Health, Livingston, NJ/Jersey City, NJ
| | - Richard S. Yoon
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center–RWJBarnabas Health, Livingston, NJ/Jersey City, NJ
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8
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Raso J, Kamalapathy PN, Sumpter A, Ramamurti P, Werner BC. Economic and educational disparities are associated with an increased risk of revision surgery following shoulder arthroplasty. J Shoulder Elbow Surg 2023; 32:589-596. [PMID: 36179962 DOI: 10.1016/j.jse.2022.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/23/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is limited literature exploring how nonmedical factors such as social determinants of health (SDOHs) are associated with postoperative outcomes following shoulder arthroplasty. METHODS A retrospective cohort review of the Pearl Diver Database was used to capture patients undergoing either primary anatomic total or reverse shoulder arthroplasty from the fourth quarter of 2015 to the third quarter of 2019 with at least 1 year of active longitudinal follow-up. Patients with proximal humeral fractures, stress fractures, or septic arthritis were excluded. The included patients were then divided into 2 cohorts based on the presence of current SDOHs or a history of SDOHs. The SDOH cohort comprised 4 non-mutually exclusive categories: economic, educational, social, and environmental disparities. Subsequently, a control cohort was matched at a 1:1 ratio to the SDOH cohort. Primary outcome measures were assessed using a logistic regression and consisted of the following 90-day postoperative complications: minor and major medical complications and infection. Emergency department (ED) visits and readmissions for any cause were also assessed. Additionally, the following 1-year outcomes were assessed: aseptic loosening, instability, and revision arthroplasty. Surgical costs and 90-day postoperative costs were collected using averaged insurance reimbursements for both the control and SDOH cohorts. RESULTS There were 5190 patients in each cohort. Economic disparities made up the largest portion of the SDOH cohort (n = 4631, 89.2%), followed by social (n = 741, 14.3%), environmental (n = 417, 8.0%), and educational (n = 99, 1.9%) disparities. Compared with the control cohort, SDOHs were associated with an increased risk of major complications (2.3% vs. 1.4%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.29-1.87; P < .001), minor complications (5.7% vs. 3.8%; OR, 1.62; 95% CI, 1.21-1.95; P = .001), readmissions (4.3% vs. 2.8%; OR, 1.56; 95% CI, 1.26-1.84; P < .001), and ED visits (15.2% vs. 11.0%; OR, 1.45; 95% CI, 1.29-1.63; P < .001) within 90 days following surgery. Additionally, SDOHs were associated with an increased risk of aseptic loosening (1.1% vs. 0.6%; OR, 1.85; 95% CI, 1.20-2.65; P = .006), instability (4.0% vs. 2.2%; OR, 1.80; 95% CI, 1.43-2.28; P < .001), and ipsilateral revision (9.2% vs. 7.6%; OR, 1.24; 95% CI, 1.08-1.43; P < .001) at 1 year postoperatively compared with the control cohort. CONCLUSION SDOHs are associated with increased rates of adverse outcomes following shoulder arthroplasty including revision surgery, ED visits, length of stay, and overall cost compared with matched controls without SDOHs. Specifically, economic and educational disparities are associated with increased rates of adverse outcomes following surgery including revision surgery, ED visits, length of stay, and overall cost.
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Affiliation(s)
- Jon Raso
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Pramod N Kamalapathy
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Anna Sumpter
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Pradip Ramamurti
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.
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9
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Heffernan JM, McLaren AC, Glass CM, Overstreet DJ. Extended Release of Bupivacaine from Temperature-responsive Hydrogels Provides Multi-day Analgesia for Postoperative Pain. PAIN MEDICINE 2023; 24:113-121. [PMID: 35944219 DOI: 10.1093/pm/pnac119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE A local anesthetic that provides analgesia lasting at least three days could significantly improve postoperative pain management. This study evaluated the analgesic efficacy and safety of an extended-release formulation of bupivacaine based on the injectable hydrogel carrier poly(N-isopropylacrylamide-co-dimethylbutyrolactone acrylamide-co-Jeffamine M-1000 acrylamide) (PNDJ). METHODS The efficacy of PNDJ containing 4% bupivacaine (SBG004) given by peri-incisional subcutaneous injection (SBG004 SC) or wound filling instillation (SBG004 WF) was evaluated compared to saline, liposomal bupivacaine, bupivacaine collagen sponge, bupivacaine-meloxicam polyorthoester, and bupivacaine HCl in a porcine skin and muscle incision model. Mechanical allodynia was assessed by withdrawal from application of von Frey filaments, and local tolerance was evaluated by histology. Bupivacaine pharmacokinetics for SBG004 SC were measured in rabbits (16.5 mg bupivacaine/kg). RESULTS Animals demonstrated less mechanical allodynia at incisions receiving SBG004 SC for up to 96 hours postoperatively. Incisions treated with SBG004 SC tolerated more force without a withdrawal indicative of pain compared to saline for 96 hours, and compared to SBG004 WF and all active controls at 24, 48, and 72 hours except bupivacaine-meloxicam polyorthoester at 72 hours. By 49 days, SBG004 was histologically absent and was replaced with granulation tissue infiltrated with immune cells in some areas. In rabbits, Cmax was 41.6 ± 9.7 ng/mL with t1/2 82.0 ± 35.8 hours (mean ± SD). CONCLUSIONS Peri-incisional SBG004 SC provided extended release of bupivacaine sufficient to reduce sensation of incisional pain for 96 hours, in vivo bupivacaine delivery for at least 7 days, and a favorable local and systemic toxicity profile.
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Affiliation(s)
| | - Alex C McLaren
- Sonoran Biosciences, Tempe, Arizona, USA.,Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Christopher M Glass
- School of Biological & Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - Derek J Overstreet
- Sonoran Biosciences, Tempe, Arizona, USA.,School of Biological & Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
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10
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Crijns TJ, Segina P, Kortlever JTP, Thomas JE, Ring D, Reichel L, Vagner G, Ramtin S. Moderators and Mediators of the Relationship of Shared Decision-Making and Satisfaction. J Patient Exp 2023; 10:23743735231171563. [PMID: 37138951 PMCID: PMC10150427 DOI: 10.1177/23743735231171563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
Background:Evidence suggests that health literacy, perceived availability of information and guidance to adapt to challenges (informational support), and symptoms of depression all have the potential to mediate or moderate the relationship between patient-rated involvement in decisions and satisfaction with care. If so these could be useful targets for improving patient experience. Methods: We prospectively enrolled 130 new adult patients visiting an orthopedic surgeon over a 4-month period. All patients were asked to complete measures of satisfaction with care (21-item Medical Interview Satisfaction Scale), perceived involvement in decisions (9-item Shared Decision-Making Questionnaire), symptoms of depression (the Patient-Reported Outcomes Measurement Information Scale [PROMIS] Depression Computerized Adaptive Test [CAT]), perceived availability of information and guidance to adapt to challenges (PROMIS Informational Support CAT), and the Newest Vital Sign test of health literacy. Results: The strong correlation between satisfaction with care (ρ = 0.60, P < .001) and perceived involvement in decisions was neither mediated nor moderated by health literacy, perceived availability of information and guidance, and symptoms of depression. Conclusions: The observation that patient-rated shared decision-making is strongly related to satisfaction with an office visit, independent of health literacy, perceived support, and symptoms of depression, is consistent with evidence that various measures of patient experience tend to correlate and emphasizes the importance of the patient-clinician relationship. Level of Evidence: Level II, prospective study.
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Affiliation(s)
- Tom J Crijns
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Paxton Segina
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Joost T P Kortlever
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Jacob E Thomas
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - David Ring
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
- David Ring, Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Health Discovery Building 6.706; 1701 Trinity St., Austin, TX 78712, USA.
| | - Lee Reichel
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Gregg Vagner
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
| | - Sina Ramtin
- Department of Surgery and
Perioperative Care, Dell Medical School, The University of Texas at Austin,
Austin, TX, USA
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Puzzitiello RN, Colliton EM, Swanson DP, Menendez ME, Moverman MA, Hart PA, Allen AE, Kirsch JM, Jawa A. Patients with limited health literacy have worse preoperative function and pain control and experience prolonged hospitalizations following shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:2473-2480. [PMID: 35671931 DOI: 10.1016/j.jse.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/30/2022] [Accepted: 05/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption. METHODS We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables. RESULTS Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P = .002), more self-reported allergies (P = .007), and worse American Shoulder and Elbow Surgeons scores (P = .001), visual analog scale pain scores (P = .020), forward elevation (P < .001), and external rotation (P = .022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P > .05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P = .012) but did not differ in terms of total hospitalization costs (P = .65) or total inpatient opioid consumption (P = .721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P = .035). CONCLUSION LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning.
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Affiliation(s)
- Richard N Puzzitiello
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA; Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA.
| | - Eileen M Colliton
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA; Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | | | - Mariano E Menendez
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Michael A Moverman
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA; Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
| | - Paul A Hart
- Boston Sports and Shoulder Center, Waltham, MA, USA
| | | | - Jacob M Kirsch
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Andrew Jawa
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
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Social Determinants of Health Disparities are Associated with Increased Costs, Revisions, and Infection in Patients Undergoing Arthroscopic Rotator Cuff Repair. Arthroscopy 2022; 39:673-679.e4. [PMID: 37194108 DOI: 10.1016/j.arthro.2022.10.011] [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: 03/14/2022] [Revised: 09/23/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The purpose of this study was to use a national claims database to assess the impact of pre-existing social determinants of health disparities (SDHD) on postoperative outcomes following rotator cuff repair (RCR). METHODS A retrospective review of the Mariner Claims Database was used to capture patients undergoing primary RCR with at least 1 year of follow-up. These patients were divided into two cohorts based on the presence of a current or previous history of SDHD, encompassing educational, environmental, social, or economic disparities. Records were queried for 90-day postoperative complications, consisting of minor and major medical complications, emergency department (ED) visits, readmission, stiffness, and 1-year ipsilateral revision surgery. Multivariate logistic regression was employed to assess the impact of SDHD on the assessed postoperative outcomes following RCR. RESULTS 58,748 patients undergoing primary RCR with a SDHD diagnosis and 58,748 patients in the matched control group were included. A previous diagnosis of SDHD was associated with an increased risk of ED visits (OR 1.22, 95% CI 1.18-1.27; P < .001), postoperative stiffness (OR 2.53, 95% CI 2.42-2.64; P < .001), and revision surgery (OR 2.35, 95% CI 2.13-2.59; P < .001) compared to the matched control group. Subgroup analysis revealed educational disparities had the greatest risk for 1-year revision (OR 3.13, 95% CI 2.53-4.05; P < .001). CONCLUSIONS The presence of a SDHD was associated with an increased risk of revision surgery, postoperative stiffness, emergency room visits, medical complications, and surgical costs following arthroscopic RCR. Overall, economic and educational SDHD were associated with the greatest risk of 1-year revision surgery. LEVEL OF EVIDENCE III, retrospective cohort study.
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Magone KM, Ben-Ari E, Gordan D, Pines Y, Boin MA, Kwon YW, Zuckerman JD, Virk MS. Analysis of Patient’s Willingness and Concerns for Discharge Following Shoulder Arthroplasty. JSES Int 2022; 6:429-433. [PMID: 35572437 PMCID: PMC9091749 DOI: 10.1016/j.jseint.2021.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Patient's willingness and barriers for discharge after shoulder arthroplasty (SA) has not been studied. The aim of this study was to prospectively analyze patient's willingness for discharge and barriers to discharge beyond postoperative day #1 (POD#1) after SA. Methods In this prospective study, patients undergoing primary or revision SA (anatomic, reverse, or hemiarthroplasty) at our institution were enrolled to determine their willingness and concerns for discharge after SA. Patient's willingness for discharge was inquired daily until discharge. Demographic information, patient's medical history, intraoperative details (duration of surgery, estimated blood loss, intraoperative complication), discharge disposition, length of stay (LOS), and reasons for extension of LOS beyond POD#1 were analyzed. Results A total of 184 patients who underwent SA were included. Eight patients were discharged on POD#0, 114 patients on POD#1, 37 patients on POD#2, and 25 patients after POD#2. One hundred nineteen (119) patients were discharged to home, 40 were discharged to home with services, 15 were discharged to nursing facilities, and 10 were discharged to rehabilitation centers. Reasons for extension of LOS past POD#1 included patients failing to clear home safety evaluation (n = 4), inadequate pain control (n = 6), worsening of preexisting medical conditions (n = 8), delay in patient disposition (awaiting placement in a rehabilitation facility [n = 6] and awaiting culture results [n = 9]). Social reasons (n = 29) were the most common reasons for extension of LOS. These included patients requesting an extra day of stay (n = 20), patients requesting rehabilitation facility placement (n = 5), lack of a timely ride home (n = 2), and family-related reasons (death in the family [n = 1], lack of home help [n = 1]). Conclusions This prospective study demonstrates modifiable factors associated with LOS beyond POD#1 (inadequate pain control, logistic delays in disposition, and patient-related social concerns) after SA. With increasing interest in same-day discharge and rising concerns to control cost and use bundled payment initiatives with SA, improving patient's willingness to discharge by addressing their concerns can improve early discharge after SA.
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Affiliation(s)
- Kevin M. Magone
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman, School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Erel Ben-Ari
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman, School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
- Division of Orthopaedic Surgery, Tel-Hashomer “Sheba” Medical Center, Sackler School of Medicine, Ramat Gan, Israel
| | - Dan Gordan
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman, School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Yaniv Pines
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman, School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Michael A. Boin
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman, School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Young W. Kwon
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman, School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Joseph D. Zuckerman
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman, School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Mandeep S. Virk
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman, School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
- Corresponding author: Mandeep S. Virk, MD, Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA.
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COVID-19 as a Catalyst for Same-Day Discharge Total Shoulder Arthroplasty. J Clin Med 2021; 10:jcm10245908. [PMID: 34945204 PMCID: PMC8709337 DOI: 10.3390/jcm10245908] [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] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 12/02/2022] Open
Abstract
The COVID-19 pandemic caused major disruptions to the healthcare system, but its impact on the transition to same-day discharge shoulder arthroplasty remains unexplored. This study assessed the effect of COVID-19 on length of stay (LOS), same-day discharge rates, and other markers of resource use after elective total shoulder arthroplasty. A total of 508 consecutive patients undergoing elective primary total shoulder arthroplasty between 2019 and 2021 were identified and divided into 2 cohorts: “pre-COVID” (March 2019–March 2020; n = 263) and “post-COVID” (May 2020–March 2021; n = 245). No elective shoulder arthroplasties were performed at our practice between 18 March and 11 May 2020. Outcome measures included LOS, same-day discharge, discharge location, and 90-day emergency department (ED) visits, readmissions and reoperations. There were no significant differences in baseline preoperative patient characteristics. Shoulder arthroplasty performed post-COVID was associated with a shorter LOS (12 vs. 16 h, p = 0.017) and a higher rate of same-day discharge (87.3 vs. 79.1%, p = 0.013). The rate of discharge to skilled nursing facilities was similarly low between the groups (1.9 vs. 2.0%, p = 0.915). There was a significant reduction in the rate of 90-day ED visits post-COVID (7.4 vs. 13.3%, p = 0.029), while there were no differences in 90-day reoperation (2.0 vs. 1.5%, p = 0.745) or readmission rates (1.2 vs. 1.9%, p = 0.724). The COVID-19 pandemic seems to have accelerated the shift towards shorter stays and more same-day discharge shoulder arthroplasties, while reducing unexpected acute health needs (e.g., ED visits) without adversely affecting readmission and reoperation rates.
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Kumari M, Padhi S, Sharma S, Phukon LC, Singh SP, Rai AK. Biotechnological potential of psychrophilic microorganisms as the source of cold-active enzymes in food processing applications. 3 Biotech 2021; 11:479. [PMID: 34790503 DOI: 10.1007/s13205-021-03008-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/29/2021] [Indexed: 12/13/2022] Open
Abstract
Microorganisms striving in extreme environments and exhibiting optimal growth and reproduction at low temperatures, otherwise known as psychrophilic microorganisms, are potential sources of cold-active enzymes. Owing to higher stability and cold activity, these enzymes are gaining enormous attention in numerous industrial bioprocesses. Applications of several cold-active enzymes have been established in the food industry, e.g., β-galactosidase, pectinase, proteases, amylases, xylanases, pullulanases, lipases, and β-mannanases. The enzyme engineering approaches and the accumulating knowledge of protein structure and function have made it possible to improve the catalytic properties of interest and express the candidate enzyme in a heterologous host for a higher level of enzyme production. This review compiles the relevant and recent information on the potential uses of different cold-active enzymes in the food industry.
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Affiliation(s)
- Megha Kumari
- Institute of Bioresources and Sustainable Development, Regional Centre, Sikkim, India
| | - Srichandan Padhi
- Institute of Bioresources and Sustainable Development, Regional Centre, Sikkim, India
| | - Swati Sharma
- Institute of Bioresources and Sustainable Development, Regional Centre, Sikkim, India
| | - Loreni Chiring Phukon
- Institute of Bioresources and Sustainable Development, Regional Centre, Sikkim, India
| | - Sudhir P Singh
- Centre of Innovative and Applied Bioprocessing, Mohali, India
| | - Amit Kumar Rai
- Institute of Bioresources and Sustainable Development, Regional Centre, Sikkim, India
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Stolberg-Stolberg J, Köppe J, Rischen R, Freistühler M, Faldum A, Katthagen JC, Raschke MJ. [Influence of complications and comorbidities on length of hospital stay and costs for surgical treatment of proximal humeral fractures]. Chirurg 2021; 92:907-915. [PMID: 34533598 PMCID: PMC8463392 DOI: 10.1007/s00104-021-01491-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/30/2022]
Abstract
Nach proximaler Humerusfraktur beim alten Patienten stellen die winkelstabile Plattenosteosynthese und die inverse Schulterendoprothese zwei konkurrierende Operationsverfahren dar. Auch wenn erste klinische Studien auf eine funktionelle Überlegenheit der inversen Schulterendoprothese hindeuten, fehlt ein gesundheitsökonomischer Vergleich in der Literatur. Krankenkassendaten von 55.070 Patienten ab einem Alter von 65 Jahren, welche nach proximaler Humerusfraktur mittels inverser Schulterendoprothese oder winkelstabiler Plattenosteosynthese versorgt worden sind, wurden auf Kosten und Liegedauer untersucht. Multivariable lineare Regressionsmodelle wurden zur Beurteilung von Komplikationen und Komorbiditäten gerechnet. Die Liegedauer nach inverser Schulterendoprothese war mit 20,0 (±13,5) Tagen statistisch auffällig länger als nach winkelstabiler Plattenosteosynthese mit 14,6 (±11,4) Tagen (p < 0,001). Die Kosten pro Fall unterschieden sich mit 11.165,70 (±5884,36) EUR für die inverser Prothese und 7030,11 (±5532,02) EUR für die Plattenosteosynthese deutlich (p < 0,001). Statistisch auffällige Kostensteigerungen durch Komplikationen und Komorbiditäten unterstreichen den Bedarf an spezialisierten geriatrischen Traumazentren.
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Affiliation(s)
- Josef Stolberg-Stolberg
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland.
| | - Jeanette Köppe
- Institut für Biometrie und Klinische Forschung, Westfälische Wilhelms-Universität Münster, Schmeddingstraße 56, 48149, Münster, Deutschland
| | - Robert Rischen
- Klinik für Radiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Moritz Freistühler
- Geschäftsbereich Medizinisches Management-Medizincontrolling, Universitätsklinikum Münster, Niels-Stensen-Straße 8, 48149, Münster, Deutschland
| | - Andreas Faldum
- Institut für Biometrie und Klinische Forschung, Westfälische Wilhelms-Universität Münster, Schmeddingstraße 56, 48149, Münster, Deutschland
| | - J Christoph Katthagen
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
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Menendez ME, Mahendraraj KA, Grubhofer F, Muniz AR, Warner JJP, Jawa A. Variation in the value of total shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:1924-1930. [PMID: 33290854 DOI: 10.1016/j.jse.2020.10.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is growing interest in maximizing value for patients undergoing discretionary orthopedic surgery but little data to guide improvement efforts. Integrating patient-reported outcomes with time-driven activity-based costing, we explored patient-level variation in the value of total shoulder arthroplasty (TSA) and characterized factors that contribute to this variation. METHODS Using our institutional registry, we identified 239 patients undergoing elective primary TSA (anatomic or reverse) between 2016-2017 with minimum 2-year follow-up. We calculated value as 2-year postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores divided by hospitalization time-driven activity-based costs. This number was multiplied by a constant to set the minimum value of TSA to 100. Multivariable linear regression modeling was performed to characterize factors underlying variation in value. RESULTS The value of shoulder arthroplasty ranged from 100 to 680, resulting in a variation of 580%. Reverse shoulder arthroplasty was associated with decreased value (79-point decrease vs. anatomic arthroplasty; P < .001; partial R2 = 0.089), as were prior ipsilateral shoulder surgery (38-point decrease; P = .002; partial R2 = 0.031), more self-reported allergies (4-point decrease per 1-unit increase; P = .029; partial R2 = 0.015), diabetes (33-point decrease; P = .045; partial R2 = 0.013), and lower preoperative ASES score (0.7-point increase per 1-unit increase; P = .045; partial R2 = 0.012). CONCLUSIONS We observed wide variation in the value of shoulder arthroplasty that was most strongly associated with procedure type and certain preoperative characteristics (eg, prior shoulder surgery, number of self-reported allergies, diabetes, ASES score). Awareness of these associations is important for implementation of targeted strategies to effectively reduce variation and redirect resources toward higher-value, cost-conscious care.
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Affiliation(s)
- Mariano E Menendez
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA
| | | | - Florian Grubhofer
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andres R Muniz
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon J P Warner
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Jawa
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA.
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Ahmed AF, Hantouly A, Toubasi A, Alzobi O, Mahmoud S, Qaimkhani S, Ahmed GO, Al Dosari MAA. The safety of outpatient total shoulder arthroplasty: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2021; 45:697-710. [PMID: 33486581 PMCID: PMC7892728 DOI: 10.1007/s00264-021-04940-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/07/2021] [Indexed: 11/09/2022]
Abstract
Purpose To meet the increasing demands of total shoulder arthroplasty (TSA) while reducing its financial burden, there has been a shift toward outpatient surgery. This systematic review and meta-analysis aimed to evaluate the safety of outpatient TSA. Methods The primary objective was to compare re-admission rates and postoperative complications in outpatient versus inpatient TSA. The secondary objectives were functional outcomes and costs. PubMed, Google Scholar, and Web of Science were searched until March 28, 2020. The inclusion criteria were studies reporting at least complications or readmission rates within a period of 30 days or more. Results Ten level III retrospective studies were included with 7637 (3.8%) and 192,025 (96.2%) patients underwent outpatient and inpatient TSA, respectively. Outpatient TSA had relatively younger and healthier patients. There were no differences between outpatient and inpatient arthroplasty for 30- and 90-day readmissions. Furthermore, unadjusted comparisons demonstrated significantly less total and major surgical complications, less total, major, and minor medical complications in favour of outpatient TSA. However, subgroup analyses demonstrated that there were no significant differences in all complication if the studies had matched controls and regardless of data source (database or nondatabase studies). The revision rates were similar between both groups at a 12–24 months follow-up. Two studies reported a significant reduction in costs in favour of outpatient TSA. Conclusion This study highlights that outpatient TSA could be a safe and effective alternative to inpatient TSA in appropriately selected patients. It was evident that outpatient TSA does not lead to increased readmissions, complications, or revision rates. A potential additional benefit of outpatient TSA was cost reduction. Supplementary Information The online version contains supplementary material available at 10.1007/s00264-021-04940-7.
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Affiliation(s)
- Abdulaziz F Ahmed
- Section of Orthopedics, Department of Surgery, Orthopaedic Surgery Resident, Hamad General Hospital, PO Box 3050, Doha, Qatar.
| | - Ashraf Hantouly
- Section of Orthopedics, Department of Surgery, Orthopaedic Surgery Resident, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Ammar Toubasi
- Section of Orthopedics, Department of Surgery, Orthopaedic Surgery Resident, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Osama Alzobi
- Section of Orthopedics, Department of Surgery, Orthopaedic Surgery Resident, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Shady Mahmoud
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Saeed Qaimkhani
- Section of Orthopedics, Department of Surgery, Orthopaedic Surgery Resident, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Ghalib O Ahmed
- Section of Orthopedics, Department of Surgery, Orthopaedic Surgery Resident, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Mohammed Al Ateeq Al Dosari
- Section of Orthopedics, Department of Surgery, Orthopaedic Surgery Resident, Hamad General Hospital, PO Box 3050, Doha, Qatar
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Belay ES, Flamant E, Sugarman B, Goltz DE, Klifto CS, Anakwenze O. Utility of postoperative hemoglobin testing following total shoulder arthroplasty. JSES Int 2020; 5:149-153. [PMID: 33554180 PMCID: PMC7846688 DOI: 10.1016/j.jseint.2020.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Identifying areas of excess cost for shoulder arthroplasty patients can play a role in effective health care spending. The purpose of this study was to assess the utility of postoperative complete blood count (CBC) testing after total shoulder arthroplasty (TSA) and identify which patients benefit from routine CBC testing. Methods We performed a retrospective review of a cohort of patients who underwent primary TSA from January 2018 through January 2019. All patients in this cohort received tranexamic acid. Patient demographic characteristics and patient-specific risk factors such as American Society of Anesthesiologists score, Elixhauser index, body mass index, smoking status, and coagulopathy history were obtained. Perioperative values including length of surgery, preoperative and postoperative hemoglobin (Hgb) levels, and need for transfusion were also obtained. Results This study included 387 TSA patients in the final analysis. Comparison between the cohort requiring transfusion and the cohort undergoing no intervention revealed no statistically significant differences in age, sex, body mass index, American Society of Anesthesiologists score, or Elixhauser index. The group receiving transfusions was found to have significantly lower levels of preoperative Hgb (11.3 g/dL) and postoperative Hgb (8.1 g/dL) (P < .0001). Additionally, the percentages of patients with abnormal preoperative Hgb levels (<12 g/dL) (72.3%) and postoperative day 1 Hgb levels < 9 g/dL (81.8%) were significantly higher in the group receiving transfusions (P < .0001). A multivariate regression model identified an abnormal preoperative Hgb level (<12 g/dL), with an odds ratio of 3.8 (95% confidence interval, 1.5-6.2; P < .001), and postoperative day 1 Hgb level < 9 g/dL, with an odds ratio of 3.3 (95% confidence interval, 0.4-6.1; P < .03), as significant predictors of the risk of transfusion with a sensitivity of 64% and specificity of 96.2% with an area under the curve of 0.87. Conclusion Routine CBC testing may not be necessary for patients who receive tranexamic acid and have preoperative Hgb levels > 12 mg/dL and first postoperative Hgb levels > 9 mg/dL. This translates to potential health care cost savings and improves current evidence-based perioperative management in shoulder arthroplasty.
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Affiliation(s)
- Elshaday S Belay
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | | | - Daniel E Goltz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oke Anakwenze
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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