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Momtaz D, Ghali A, Ahmad F, Gonuguntla R, Kotzur T, Wang RJ, Ghilzai U, Abbas A, Wu C. Effective Risk Assessment for Distal Radius Fractures: A Rigorous Multivariable Regression Analysis, Using a Novel 8-Item Modified Frailty Index. J Wrist Surg 2024; 13:120-126. [PMID: 38505209 PMCID: PMC10948243 DOI: 10.1055/s-0043-1764203] [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: 10/11/2022] [Accepted: 01/24/2023] [Indexed: 03/21/2024]
Abstract
Introduction Distal radius fractures (DRFs) are among the most common orthopaedic injuries. The prevalence of DRFs is increasing across all age groups but remains the second most common fracture in the elderly. The modified frailty index (MFI) often predicts morbidity and mortality in orthopaedic injuries. This study aims to determine the predictive value of MFI on complication rates following DRF and the patient length of stay and discharge outcomes. Methods We utilized our MFI to perform a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Results In a total of 22,313 patients, the average age was 46 ± 16. An increase in MFI led to an increase in the odds ratio of readmission and reoperation ( p < 0.001). MFI predicted complications, doubling the rate as the score increased from 1 to 2 ( p < 0.001). An MFI of 2 also led to a delayed hospital stay of 5 days ( p < 0.001), as well as an increase in the odds of patients not being sent home at discharge ( p < 0.001). Finally, life-threatening complications were also predicted with an increased MFI, the odds of a life-threatening complication increasing 488.20 times at an MFI of 3 ( p < 0.001). Discussion and Conclusion While surgical decision-making for frail patients with DRFs remains contentious, this novel 8-item MFI score was significantly associated with the probability of hospital readmission/reoperation, postoperative complications, and delayed hospital length of stay. Three new parameters were incorporated into our 8-item score compared with the conventional 5; hypoalbuminemia status (< 3.5 mg/dL), previous diagnosis of osteoporosis, and severe obesity (body mass index > 35) enhancing its sensitivity. Future studies are warranted for its prospective utility in ruling out postsurgical comorbidity.
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Affiliation(s)
- David Momtaz
- Department of Orthopaedics, UT Health San Antonio, San Antonio, Texas
| | - Abdullah Ghali
- Department of Orthopaedics, Baylor College of Medicine, Houston, Texas
| | - Farhan Ahmad
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois
| | - Rishi Gonuguntla
- Department of Orthopaedics, UT Health San Antonio, San Antonio, Texas
| | - Travis Kotzur
- Department of Orthopaedics, UT Health San Antonio, San Antonio, Texas
| | - Rebecca J. Wang
- Department of Orthopaedics, UT Health San Antonio, San Antonio, Texas
| | - Umar Ghilzai
- Department of Orthopaedics, Baylor College of Medicine, Houston, Texas
| | - Adam Abbas
- Department of Orthopaedics, Baylor College of Medicine, Houston, Texas
| | - Chia Wu
- Department of Orthopaedics, Baylor College of Medicine, Houston, Texas
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Karimi AH, Grits D, Shah AK, Burkhart RJ, Kamath AF. Is Discharge Within a Day Following Total Hip Arthroplasty Safe in the Septuagenarian and Octogenarian Population? A Propensity-Matched Cohort Study. J Arthroplasty 2024; 39:13-18. [PMID: 37625466 DOI: 10.1016/j.arth.2023.08.065] [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: 02/20/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Limited data exists on whether patients older than 70 can safely be discharged within a day (rapid discharge (RD)) following primary total hip arthroplasty (THA). The purpose of this study was to compare perioperative complications and readmission rates associated with RD in patients ≥70 years compared to longer lengths of stay following THA. METHODS A retrospective, propensity-matched cohort study was conducted using the National Surgical Quality Improvement Program database from 2006 to 2020. Patients ≥70 years undergoing RD following THA were propensity matched to patients ≥70 years who had longer hospital stays (nonrapid discharge). Sub-analyses were performed for septuagenarians and octogenarians. Following 1:1 matching, multivariate analyses were performed to compare perioperative complications and readmissions. Following propensity matching, both groups contained 2,192 patients. RESULTS The RD patients were found to have shorter operative times (P < .001), less bleeding complications (P < .001), and were more likely to have home discharges (P < .001). The 2 cohorts did not differ in the remaining complications or 30-day postoperative period readmissions among all patients and when evaluating septuagenarians and octogenarians. CONCLUSION Patients ≥70 years undergoing RD following THA had comparable complication and readmission rates to patients older than 70 undergoing nonrapid discharge. Furthermore, RD patients were more likely to have home discharges and have shorter operations with less bleeding complications. Septuagenarians receiving RD were more likely to have an unplanned readmission. These data suggest that RD following THA can be performed safely in select patients older than 70.
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Affiliation(s)
- Amir H Karimi
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Daniel Grits
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Aakash K Shah
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert J Burkhart
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Efford CM, Samuel D. Does rapid mobilisation as part of an enhanced recovery pathway improve length of stay, return to function and patient experience post primary total hip replacement? A randomised controlled trial feasibility study. Disabil Rehabil 2023; 45:4252-4258. [PMID: 36412168 DOI: 10.1080/09638288.2022.2148298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/12/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Day-zero ambulation may enable patients to recover and leave hospital quicker following total hip replacement (THR). The present randomised control feasibility study investigated the efficacy of day-zero ambulation as a physiotherapeutic intervention. METHODS Thirty-six non-blinded adults aged 44-85 (Mean 67.1; SD 9.6 years) undergoing primary, uncomplicated THR were block randomized to either a control group (n = 18) with standard post-operative physiotherapy or an intervention group (n = 18) incorporating walking on the same day as the operation. Outcomes were length of hospital stay (LOS), time to reach functional milestones and achieve all physiotherapy discharge criteria, post-operative pain scores, complications and patient experience. RESULTS Participants treated with day-zero ambulation had reduced median hospital LOS of 1 day (p = .096), and median reduced times to reaching functional milestones of 39.7 h quicker to transfer to a chair (p < .001), 24.5 h quicker to walk 10 m (p = .009) and 26.4 h quicker to independently ascend and descend stairs (p = .01). Participants in the intervention group were deemed physiotherapy ready to leave hospital significantly earlier than control group (1.04 days, p = .015). CONCLUSIONS Day-zero ambulation appears safe and may have clinically relevant effects in speeding patient functional recovery and facilitating earlier discharge from hospital. Implications for RehabilitationDay-zero ambulation following total hip replacement (THR) appears safe.Preliminary data suggest that day-zero mobilisation following THR could be efficacious and support the need for a fully powered randomised controlled trial.There may be a clinically relevant effect in speeding patient functional recovery and facilitating an earlier discharge from hospital.
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Affiliation(s)
- Christopher M Efford
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Dinesh Samuel
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
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4
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Kotzur T, Singh A, Vivancos Koopman I, Armstrong C, Brady N, Moore C. The Impact of Metabolic Syndrome and Obesity on Perioperative Total Joint Arthroplasty Outcomes: The Obesity Paradox and Risk Assessment in Total Joint Arthroplasty. Arthroplast Today 2023; 21:101139. [PMID: 37151404 PMCID: PMC10160687 DOI: 10.1016/j.artd.2023.101139] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/18/2023] [Indexed: 05/09/2023] Open
Abstract
Background The relationship between elevated body mass index (BMI) and adverse outcomes in joint arthroplasty is well established in the literature. This paper aims to challenge the conventional thought of excluding patients from a total knee or hip replacement based on BMI alone. Instead, we propose using the metabolic syndrome (MetS) and its defining components to better identify patients at high risk for intraoperative and postoperative complications. Methods Patients who underwent primary, elective total knee and total hip arthroplasty were identified in the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program database. Several defining components of MetS, such as hypertension, diabetes, and obesity, were compared to a metabolically healthy cohort. Postoperative outcomes assessed included mortality, length of hospital stay, 30-day surgical and medical complications, and discharge. Results The outcomes of 529,737 patients from the American College of Surgeons National Surgical Quality Improvement Program who underwent total knee and total hip arthroplasty were assessed. MetS is associated with increased complications and increased mortality. Both hypertension and diabetes are associated with increased complications but have no impact on mortality. Interestingly, while obesity was associated with increased complications, there was a significant decrease in mortality. Conclusions Our results show that the impact of MetS is more than the sum of its constitutive parts. Additionally, obese patients experience a protective effect, with lower mortality than their nonobese counterparts. This study supports moving away from strict BMI cutoffs alone for someone to be eligible for an arthroplasty surgery and offers more granular data for risk stratification and patient selection.
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Affiliation(s)
- Travis Kotzur
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
- Corresponding author. Department of Orthopaedics, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX 78229-3900, USA. Tel.: +1 210 878 8558.
| | - Aaron Singh
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
| | | | - Connor Armstrong
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
| | - Nicholas Brady
- University of New Mexico Orthopedics Department, Albuquerque, NM, USA
| | - Chance Moore
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
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Brodeur PG, Boduch A, Kim KW, Cohen EM, Gil JA, Cruz AI. Surgeon and Facility Volumes Are Associated With Social Disparities and Post-Operative Complications After Total Hip Arthroplasty. J Arthroplasty 2022; 37:S908-S918.e1. [PMID: 35151807 DOI: 10.1016/j.arth.2022.02.018] [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: 10/30/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study is to further characterize the volume dependence of facilities and surgeons on morbidity and mortality after total hip arthroplasty (THA). METHODS Adults who underwent THA from 2009 to 2014 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Complication rates were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression controlling for factors such as the Social Deprivation Index. Surgeon and facility volumes were compared between the low and high volume using cutoffs established by prior research. RESULTS In total, 99,832 patients were included. Low volume facilities had higher rates of readmission, urinary tract infection (UTI), acute renal failure, pneumonia, surgical site infection (SSI), cellulitis, wound complications, deep vein thrombosis (DVT), in-hospital mortality, and revision. Low volume surgeons had higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, acute respiratory failure, pulmonary embolism, cellulitis, wound complications, in-hospital mortality, cardiorespiratory arrest, DVT, and revision. African Americans, Hispanics, and those with federal insurance had increased rates of readmission. Those with ≥1 Charlson comorbidities or from areas of higher social deprivation had increased incidence of treatment by low volume surgeons and facilities. CONCLUSION Both low volume facilities and surgeons performing primary THA have higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, cellulitis, wound complications, DVT, in-hospital mortality, and revision. Demographic disparities exist between who is treated at low vs high volume surgeons and facilities placing those groups at higher risks for complications.
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Affiliation(s)
- Peter G Brodeur
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Abigail Boduch
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Kang Woo Kim
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Eric M Cohen
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Joseph A Gil
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
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Flanigan TL, Kiskaddon EM, Rogozinski JA, Thomas MD, Froehle AW, Krishnamurthy AB. Predictive Factors of Extended Length of Hospital Stay Following Total Joint Arthroplasty in a Veterans Affairs Hospital Population. J Arthroplasty 2021; 36:1527-1532. [PMID: 33358308 DOI: 10.1016/j.arth.2020.11.006] [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: 09/01/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Improved perioperative care for total joint arthroplasty (TJA) procedures has resulted in decreased hospital length of stay (LOS), including effective discharge on postoperative day (POD) 1 in many patients. It remains unclear what contributes to discharge delay in patients that are not discharged on POD 1. This study investigated factors associated with delayed discharge in patients whose original planned discharge was on POD 1. METHODS A retrospective cohort of 451 patients who underwent a hip or knee TJA procedure from April 2015 to March 2018 with planned discharge on POD 1 was analyzed. Patient characteristics included demographics, lab values, course of treatment, procedure, Charlson Comorbidity Index (CCI), complications, and other factors. Statistical regression was used to identify factors associated with delayed discharge; odds ratios (OR) were calculated for significant factors (α = 0.05). RESULTS Of those studied, 70/451 (15.5%) experienced a delay from the planned POD 1 discharge. An increased likelihood of delayed discharge was associated with a nonhome discharge (P < .001, OR = 8.72 [95% CI: 4.22-18.06]) and higher CCI (P = .034, OR = 1.16 [95% CI: 1.01-1.32]). Inpatient physical therapy on the day of surgery was found to significantly correlate with successful discharge on POD 1 (P = .004, OR = 0.44 [95% CI: 0.25-0.77]). CONCLUSION Most patients can be discharged on POD 1 after TJA. Physical therapy on the day of surgery increased the likelihood of patients being discharged on POD 1. Those with a higher CCI and a nonhome discharge were more likely to have a discharge delay. This information can help surgeons counsel patients and prepare for postoperative care.
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Affiliation(s)
- Trenden L Flanigan
- Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, OH
| | - Eric M Kiskaddon
- Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, OH
| | | | - Matthew D Thomas
- Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, OH
| | - Andrew W Froehle
- Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, OH; Boonshoft School of Medicine, Wright State University, Fairborn, OH
| | - Anil B Krishnamurthy
- Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, OH; Department of Orthopaedic Surgery, Dayton Veteran's Association Medical Center, Dayton, OH
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7
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The utility of the Charlson Comorbidity Index and modified Frailty Index as quality indicators in total joint arthroplasty: a retrospective cohort review. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clement RC, Strassle PD, Ostrum RF. Does Very High Surgeon or Hospital Volume Improve Outcomes for Hemiarthroplasty Following Femoral Neck Fractures? J Arthroplasty 2020; 35:1268-1274. [PMID: 31918987 DOI: 10.1016/j.arth.2019.11.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/23/2019] [Accepted: 11/30/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study evaluates whether very high-volume hip arthroplasty providers have lower complication rates than other relatively high-volume providers. METHODS Hemiarthroplasty patients ≥60 years old were identified in the New York Statewide Planning and Research Cooperative System 2001-2015 dataset. Low-volume hospitals (<50 hip arthroplasty cases/y) and surgeons (<10 cases/y) were excluded. The upper and lower quintiles were compared for the remaining "high-volume" hospitals (50-70 vs >245) and surgeons (10-15 vs ≥60) using multivariable Cox proportional hazards regression. Multiple sensitivity analyses were performed treating volume as a continuous variable. RESULTS In total, 48,809 patients were included. Very high-volume hospitals demonstrated slightly less pneumonia (6% vs 7%, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.68-0.88, P < .0001). Very high-volume surgeons experienced slightly higher rates of inpatient morality (3% vs 2%, HR 1.30, 95% CI 1.06-1.60, P = .01), revision surgery (3% vs 3%, HR 1.24, 95% CI 1.02-1.52, P = .03), and implant failure (1% vs <1%, HR 1.80, 95% CI 1.10-2.96, P = .02). Sensitivity analyses did not significantly alter these findings but suggested that inpatient mortality may decline as surgeon volume approaches 30 cases/y before gradually increasing at higher volumes. CONCLUSION A clinically meaningful volume-outcome relationship was not identified among very high-volume hemiarthroplasty surgeons or hospitals. Although prior evidence indicates that outcomes can be improved by avoiding very low-volume providers, these results suggest that complications would not be further reduced by directing all hemiarthroplasty patients to very high-volume surgeons or facilities. Future research investigating whether inpatient mortality changes with surgeon volume (particularly around 30 cases/y) in a different dataset would be valuable. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- R Carter Clement
- Department of Orthopaedic Surgery, Children's Hospital of New Orleans, New Orleans, Louisiana; Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Paula D Strassle
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Robert F Ostrum
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Ding ZC, Xu B, Liang ZM, Wang HY, Luo ZY, Zhou ZK. Limited Influence of Comorbidities on Length of Stay after Total Hip Arthroplasty: Experience of Enhanced Recovery after Surgery. Orthop Surg 2019; 12:153-161. [PMID: 31885219 PMCID: PMC7031546 DOI: 10.1111/os.12600] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 02/05/2023] Open
Abstract
Objectives To identify predictors of length of stay (LOS) after total hip arthroplasty (THA) in an enhanced recovery after surgery (ERAS) program and evaluate the safety and cost‐efficiency of the ERAS program with reduced LOS for unselected patients in a Chinese population. Methods A total of 311 consecutive, unselected patients undergoing primary THA at a single institution were retrospectively reviewed and divided into two groups: LOS ≤ 3 and LOS > 3 group. All patients were managed with the same ERAS protocol and went back home after discharge. Multivariate logistic regression analysis was used to determine independent risk factors for LOS > 3. Harris Hip Score at 90‐day follow‐up, 90‐day readmission rate, and hospitalization costs were compared between two groups. Results Multivariate regression analysis identified female gender (odds ratio [OR] = 2.623), living alone (OR = 4.127), and primary osteoarthritis of hip (OR = 3.565) to be correlated with LOS > 3. Preoperative hemoglobin (HB), postoperative HB, drain use, blood transfusion, diabetes, respiratory disease, osteoporosis, number of comorbidities, and CCI score showed no significant influence on LOS after adjusting for other risk factors in the multivariate model. Harris Hip Score and readmission rate at 90‐day follow‐up showed no significant differences between two groups. Patients in LOS > 3 group had approximately 3948.6 Chinese yuan higher hospital costs. Conclusion Female gender, living alone, and primary osteoarthritis of hip were identified as independent risk factors for prolonged LOS. The experience from our institution suggested aggressive management of comorbidities in the ERAS program can minimize the influence of comorbidities on LOS. The safety, efficiency, and costs‐saving benefits of the ERAS program with reduced LOS for unselected patients was confirmed in this study.
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Affiliation(s)
- Zi-Chuan Ding
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Bing Xu
- Department of Orthopedics, Chengdu Second People's Hospital, Chengdu, China
| | - Zhi-Min Liang
- Clinic Research Management Department, West China Hospital, Sichuan University, Chengdu, China
| | - Hao-Yang Wang
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Ze-Yu Luo
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Zong-Ke Zhou
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
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10
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Mufarrih SH, Ghani MOA, Martins RS, Qureshi NQ, Mufarrih SA, Malik AT, Noordin S. Effect of hospital volume on outcomes of total hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2019; 14:468. [PMID: 31881918 PMCID: PMC6935169 DOI: 10.1186/s13018-019-1531-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/19/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A shift in the healthcare system towards the centralization of common yet costly surgeries, such as total hip arthroplasty (THA), to high-volume centers of excellence, is an attempt to control the economic burden while simultaneously enhancing patient outcomes. The "volume-outcome" relationship suggests that hospitals performing more treatment of a given type exhibit better outcomes than hospitals performing fewer. This theory has surfaced as an important factor in determining patient outcomes following THA. We performed a systematic review with meta-analyses to review the available evidence on the impact of hospital volume on outcomes of THA. MATERIALS AND METHODS We conducted a review of PubMed (MEDLINE), OVID MEDLINE, Google Scholar, and Cochrane library of studies reporting the impact of hospital volume on THA. The studies were evaluated as per the inclusion and exclusion criteria. A total of 44 studies were included in the review. We accessed pooled data using random-effect meta-analysis. RESULTS Results of the meta-analyses show that low-volume hospitals were associated with a higher rate of surgical site infections (1.25 [1.01, 1.55]), longer length of stay (RR, 0.83[0.48-1.18]), increased cost of surgery (3.44, [2.57, 4.30]), 90-day complications (RR, 1.80[1.50-2.17]) and 30-day (RR, 2.33[1.27-4.28]), 90-day (RR, 1.26[1.05-1.51]), and 1-year mortality rates (RR, 2.26[1.32-3.88]) when compared to high-volume hospitals following THA. Except for two prospective studies, all were retrospective observational studies. CONCLUSIONS These findings demonstrate superior outcomes following THA in high-volume hospitals. Together with the reduced cost of the surgical procedure, fewer complications may contribute to saving considerable opportunity costs annually. However, a need to define objective volume-thresholds with stronger evidence would be required. TRIAL REGISTRATION PROSPERO CRD42019123776.
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Affiliation(s)
- Syed Hamza Mufarrih
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan.
| | | | | | | | | | - Azeem Tariq Malik
- Department of Orthopedics, Ohio State University, Columbus, Ohio, USA
| | - Shahryar Noordin
- Department of Orthopedic Surgery, Aga Khan University, Karachi, Pakistan
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11
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Optimal Hospital and Surgeon Volume Thresholds to Improve 30-Day Readmission Rates, Costs, and Length of Stay for Total Hip Replacement. J Arthroplasty 2019; 34:1901-1908.e1. [PMID: 31133428 DOI: 10.1016/j.arth.2019.04.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/16/2019] [Accepted: 04/23/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Little is known about whether there are optimal hospital and surgeon volume thresholds to reduce readmission, costs, and length of stay (LOS) for total hip replacement (THR). Nationwide population-based data were applied to identify the optimal hospital and surgeon volume thresholds and to discover the effects of these volume thresholds on 30-day unplanned readmission, costs and LOS for THR. METHODS A total of 6367 patients identified through Taiwan's National Health Insurance Research Database received THR in 2012. Restricted cubic splines were used to identify the optimal hospital and surgeon volume needed to decrease the risk of 30-day unplanned readmission. Multilevel regression modeling and propensity score weighting were used to examine the impact of hospital and surgeon volume thresholds on 30-day unplanned readmission, costs, and LOS, after adjusting for patient, surgeon, and hospital characteristics. RESULTS The volume thresholds for hospitals and surgeons were 65 cases and 15 cases a year, respectively. The overall mean LOS was 7.3 ± 4.3 days. Patients who received THR from surgeons who did not reach the volume threshold had higher 30-day unplanned readmission rates, costs, and LOS than those who received THR from surgeons who reached the volume threshold. CONCLUSION This is the first study to identify the surgeon volume threshold that can reduce 30-day unplanned readmission rates, costs, and LOS for THR. However, the results from Taiwan may not be applicable to other parts of the world. Identifying the threshold could help patients, providers, and policymakers to make decisions regarding optimal delivery of THR.
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12
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Malik AT, Jain N, Scharschmidt TJ, Li M, Glassman AH, Khan SN. Does Surgeon Volume Affect Outcomes Following Primary Total Hip Arthroplasty? A Systematic Review. J Arthroplasty 2018; 33:3329-3342. [PMID: 29921502 DOI: 10.1016/j.arth.2018.05.040] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/06/2018] [Accepted: 05/28/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Surgeon volume has been identified as an important factor impacting postoperative outcome in patients undergoing orthopedic surgeries. With an absence of a detailed systematic review, we sought to collate evidence on the impact of surgeon volume on postoperative outcomes in patients undergoing primary total hip arthroplasty. METHODS PubMed (MEDLINE) and Google Scholar databases were queried for articles using the following search criteria: ("Surgeon Volume" OR "Provider Volume" OR "Volume Outcome") AND ("THA" OR "Total hip replacement" OR "THR" OR "Total hip arthroplasty"). Studies investigating total hip arthroplasty being performed for malignancy or hip fractures were excluded from the review. Twenty-eight studies were included in the final review. All studies underwent a quality appraisal using the GRADE tool. The systematic review was performed in accordance with the PRISMA guidelines. RESULTS Increasing surgeon volume was associated with a shorter length of stay, lower costs, and lower dislocation rates. Studies showed a significant association between an increasing surgeon volume and higher odds of early-term and midterm survivorship, but not long-term survivorships. Although complications were reported and recorded differently in studies, there was a general trend toward a lower postoperative morbidity with regard to complications following surgeries by a high-volume surgeon. CONCLUSION This systematic review shows evidence of a trend toward better postoperative outcomes with high-volume surgeons. Future prospective studies are needed to better determine long-term postoperative outcomes such as survivorship before healthcare policies such as regionalization and/or equal-access healthcare systems can be considered.
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Affiliation(s)
- Azeem T Malik
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Nikhil Jain
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Thomas J Scharschmidt
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Mengnai Li
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Andrew H Glassman
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Safdar N Khan
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH
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The impact of metabolic syndrome on 30-day outcomes in geriatric hip fracture surgeries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:427-433. [PMID: 30196376 DOI: 10.1007/s00590-018-2298-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/18/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Past literature has reported metabolic syndrome (MetS) to complicate postoperative care in patients undergoing various surgical procedures. We sought to analyze the impact of MetS on 30-day outcomes following hip fracture surgeries in the geriatric population. MATERIALS AND METHODS The 2015-2016 ACS-NSQIP database was queried for patients undergoing hip fracture repair using CPT codes for total hip arthroplasty (27130), hemiarthroplasty (27125) and open reduction internal fixation (27236, 27244, 27245). Only patients ≥ 65 years of age undergoing surgery due to a traumatic hip fracture were included in the study. MetS was defined using preset criteria used by other NSQIP studies as the presence of-(1) diabetes mellitus AND (2) hypertension requiring medication AND (3) BMI ≥ 30 kg/m2. RESULTS Out of 31,621 patients, a total of 1388 (4.4%) geriatric patients with MetS underwent hip fracture surgery. Following adjusted analysis, the presence of MetS was associated with higher odds of a prolonged length of stay > 5 days (OR 1.14 [95% CI 1.01-1.29]; p = 0.031), deep SSI (OR 2.48 [95% CI 1.20-5.14]; p = 0.014), progressive renal insufficiency (OR 3.27 [95% CI 1.98-5.42]; p < 0.001), acute renal failure (OR 2.08 [95% CI 1.04-4.15]; p = 0.038), urinary tract infection (OR 1.43 [95% CI 1.12-1.81]; p = 0.004), 30-day readmissions (OR 1.28 [95% CI 1.08-1.52]; p = 0.005) and a non-home discharge (OR 1.42 [95% CI 1.18-1.71]; p < 0.001). CONCLUSION MetS is associated with a significantly increased risk of several postoperative complications, readmissions and non-home discharge dispositions. Providers can utilize these data to promote the need for better perioperative care in these high-risk patients.
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Okike K, Chan PH, Paxton EW. Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Hip Fracture. J Bone Joint Surg Am 2017; 99:1547-1553. [PMID: 28926384 DOI: 10.2106/jbjs.16.01133] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prior studies have examined the relationship between surgeon and hospital volumes and outcome following hip fracture surgical procedures, but the results have been inconclusive. The purpose of this study was to assess the hip fracture volume-outcome relationship by analyzing data from a large, managed care registry. METHODS The Kaiser Permanente Hip Fracture Registry prospectively records information on surgically treated hip fractures within the managed health-care system. Using this registry, all surgically treated hip fractures in patients 60 years of age or older were identified. Surgeon and hospital volume were defined as the number of hip fracture surgical procedures performed in the preceding 12 months and were divided into tertiles (low, medium, and high). The primary outcome was mortality at 1 year postoperatively. Secondary outcomes were mortality at 30 and 90 days postoperatively as well as reoperation (lifetime), medical complications (90-day), and unplanned readmission (30-day). To determine the relationship between volume and these outcome measures, multivariate logistic and Cox proportional hazards regression were performed, controlling for potentially confounding variables. RESULTS Of 14,294 patients in the study sample, the majority were female (71%) and white (79%), and the mean age was 81 years. The overall mortality rate was 6% at 30 days, 11% at 90 days, and 21% at 1 year. We did not find an association between surgeon or hospital volume and mortality at 30 days, 90 days, or 1 year (p > 0.05). There was also no association between surgeon or hospital volume and reoperation, medical complications, or unplanned readmission (p > 0.05). CONCLUSIONS In this analysis of hip fractures treated in a large integrated health-care system, the observed rates of mortality, reoperation, medical complications, and unplanned readmission did not differ by surgeon or hospital volume. In contrast to other orthopaedic procedures, such as total joint arthroplasty, our data do not suggest that hip fractures need to be preferentially directed toward high-volume surgeons or hospitals for treatment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kanu Okike
- 1Department of Orthopaedics, Kaiser Moanalua Medical Center, Honolulu, Hawaii 2Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
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Rosas S, Sabeh KG, Buller LT, Law TY, Roche MW, Hernandez VH. Medical Comorbidities Impact the Episode-of-Care Reimbursements of Total Hip Arthroplasty. J Arthroplasty 2017; 32:2082-2087. [PMID: 28318861 DOI: 10.1016/j.arth.2017.02.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/14/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) costs are a source of great interest in the currently evolving health care market. The initiation of a bundled payment system has led to further research into costs drivers of this commonly performed procedure. One aspect that has not been well studied is the effect of comorbidities on the reimbursements of THA. The purpose of this study was to determine if common medical comorbidities affect these reimbursements. METHODS A retrospective, level of evidence III study was performed using the PearlDiver supercomputer to identify patients who underwent primary THA between 2007 and 2015. Patients were stratified by medical comorbidities and compared using the analysis of variance for reimbursements of the day of surgery, and over the 90-day postoperative period. RESULTS A cohort of 250,343 patients was identified. Greatest reimbursements on the day of surgery were found among patients with a history of cirrhosis, morbid obesity, obesity, chronic kidney disease (CKD) and hepatitis C. Patients with cirrhosis, hepatitis C, chronic obstructive pulmonary disease, atrial fibrillation, and CKD incurred in the greatest reimbursements over the 90-day period after surgery. CONCLUSION Medical comorbidities significantly impact reimbursements, and inferentially costs, after THA. The most costly comorbidities at 90 days include cirrhosis, hepatitis C, chronic obstructive pulmonary disease, atrial fibrillation, and CKD.
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Affiliation(s)
- Samuel Rosas
- Department of Orthopedic Surgery, University of Miami, Miami, Florida; Department of Orthopedic Surgery, Holy Cross Hospital, Fort Lauderdale, Florida
| | - Karim G Sabeh
- Department of Orthopedic Surgery, University of Miami, Miami, Florida
| | - Leonard T Buller
- Department of Orthopedic Surgery, University of Miami, Miami, Florida
| | - Tsun Yee Law
- Department of Orthopedic Surgery, Holy Cross Hospital, Fort Lauderdale, Florida
| | - Martin W Roche
- Department of Orthopedic Surgery, Holy Cross Hospital, Fort Lauderdale, Florida
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16
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Lakomkin N, Goz V, Lajam CM, Iorio R, Bosco JA. Higher Modified Charlson Index Scores Are Associated With Increased Incidence of Complications, Transfusion Events, and Length of Stay Following Revision Hip Arthroplasty. J Arthroplasty 2017; 32:1121-1124. [PMID: 28109762 DOI: 10.1016/j.arth.2016.11.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/20/2016] [Accepted: 11/09/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Revision total hip arthroplasty (RHA) has been associated with greater morbidity and length of stay (LOS) compared to primary total hip arthroplasty. Despite this, few validated metrics exist for risk stratification in RHA cohorts. The Charlson Comorbidity Index (CCI) has been associated with complications in total hip arthroplasty, but its utility in revision surgery remains unexplored. The purpose of this study was to examine the relationship between preoperative CCI and a variety of outcome metrics following RHA. METHODS The National Surgical Quality Improvement Program database was used to identify all patients undergoing aseptic RHA between 2006 and 2013. A variety of demographics and perioperative variables were collected. Modified CCI scores were computed for each patient based on a validated formula incorporating comorbidities found in the National Surgical Quality Improvement Program database. Outcome variables of interest included mortality, major postoperative complications, minor adverse events, incidence of transfusion, and prolonged LOS. Perioperative factors were tested for association with these outcomes using bivariate analysis and significant variables were then incorporated into a logistic regression model to explore the relationship between preoperative CCI scores and postoperative events. RESULTS In a multivariable regression model controlling for the significant perioperative variables, operative time, and American Society of Anesthesiologists classification, higher CCI scores were significantly associated with mortality (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.64-2.18, P < .001), major complications (OR 1.12, 95% CI 1.05-1.20, P = .001), minor complications (OR 1.53, 95% CI 1.39-1.69, P < .001), transfusions (OR 1.14, 95% CI 1.09-1.20, P < .001), and prolonged LOS (OR 1.32, 95% CI 1.26-1.39, P < .001). CONCLUSION Higher preoperative CCI scores were independent risk factors for numerous complications. This highlights the potential utility of the CCI in risk stratification for RHA populations.
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Affiliation(s)
- Nikita Lakomkin
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York
| | - Vadim Goz
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Claudette M Lajam
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York
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Nichols CI, Vose JG. Patient Comorbidity Status and Incremental Total Hospitalization Costs in Elective Orthopedic Procedures. Orthopedics 2016; 39:237-46. [PMID: 27322174 DOI: 10.3928/01477447-20160610-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/13/2015] [Indexed: 02/03/2023]
Abstract
This study examined the correlation between patient comorbidity status, hospitalization length of stay (LOS), and cost for total knee arthroplasty (TKA), total hip arthroplasty (THA), and 1- to 3-level lumbar spinal fusion procedures. Using the Premier Perspective Database, adults older than 18 years who underwent primary unilateral TKA, THA, or spinal fusion between January 1, 2008, and June 30, 2014, were identified. Generalized linear models controlling for age, sex, region, hospital size, academic status, payor, and procedure year predicted the incremental total hospitalization cost among the sickest patients (Charlson Comorbidity Index [CCI] ≥3) vs healthy controls (CCI=0). The study cohort included 536,582 TKAs, 275,953 THAs, and 177,493 spinal fusion procedures. The percentages of patients with a CCI of 3 or greater were 5.4%, 4.7%, and 4.3%, for TKA, THA, and spinal fusion procedures, respectively. Mean (SD) LOS was longer by 0.9 (1.5), 1.4 (2.3), and 2.3 (3.8) days for patients with a CCI of 3 or greater vs 0 for TKA, THA, and spinal fusion procedures, respectively. Unadjusted total hospitalization costs were $17,512 for TKA, $18,915 for THA, and $32,932 for spinal fusion procedures; generalized linear models showed an incremental total hospitalization cost for CCI scores of 3 or greater of $2211, $3041, and $3922 vs CCI equal to 0 for each procedure type, respectively. Although representing a relatively small proportion of all patients undergoing elective orthopedic procedures, highly comorbid patients were associated with a greater total hospitalization cost burden. With the average patient comorbidity burden growing nationally, this study warrants further examination of improved standards of care for comorbid patients undergoing elective orthopedic procedures. [Orthopedics. 2016; 39(4):237-246.].
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18
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Glassou EN, Hansen TB, Mäkelä K, Havelin LI, Furnes O, Badawy M, Kärrholm J, Garellick G, Eskelinen A, Pedersen AB. Association between hospital procedure volume and risk of revision after total hip arthroplasty: a population-based study within the Nordic Arthroplasty Register Association database. Osteoarthritis Cartilage 2016; 24:419-26. [PMID: 26432511 DOI: 10.1016/j.joca.2015.09.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 09/17/2015] [Accepted: 09/21/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Outcome after total hip arthroplasty (THA) depends on several factors related to the patient, the surgeon and the implant. It has been suggested that the annual number of procedures per hospital affects the prognosis. We aimed to examine if hospital procedure volume was associated with the risk of revision after primary THA in the Nordic countries from 1995 to 2011. DESIGN The Nordic Arthroplasty Register Association database provided information about primary THA, revision and annual hospital volume. Hospitals were divided into five volume groups (1-50, 51-100, 101-200, 201-300, >300). The outcome of interest was risk of revision 1, 2, 5, 10 and 15 years after primary THA. Multivariable regression was used to assess the relative risk (RR) of revision. RESULTS 417,687 THAs were included. For the 263,176 cemented THAs no differences were seen 1 year after primary procedure. At 2, 5, 10 and 15 years the four largest hospital volume groups had a reduced risk of revision compared to group 1-50. After 10 years RR was for volume group 51-100 0.79 (CI 0.65-0.95), group 101-200 0.76 (CI 0.61-0.95), group 201-300 0.74 (CI 0.57-0.96) and group >300 0.57 (CI 0.46-0.71). For the uncemented THAs an association between hospital volume and risk of revision were only present for hospitals producing 201-300 THAs per year, beginning at years 2 through 5 and in all subsequent time intervals to 15 years. CONCLUSION Hospital procedure volume was associated with a long term risk of revision after primary cemented THA. Hospitals operating 50 procedures or less per year had an increased risk of revision after 2, 5, 10 and 15 years follow up.
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Affiliation(s)
- E N Glassou
- University Clinic for Hand, Hip and Knee Surgery, Regional Hospital West Jutland, Aarhus University, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Denmark.
| | - T B Hansen
- University Clinic for Hand, Hip and Knee Surgery, Regional Hospital West Jutland, Aarhus University, Denmark.
| | - K Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland.
| | - L I Havelin
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.
| | - O Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.
| | - M Badawy
- Kysthospital in Hagavik, Haukeland University Hospital, Bergen, Norway.
| | - J Kärrholm
- Institute of Clinical Sciences, Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden; Swedish Hip Arthroplasty Register, Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - G Garellick
- Institute of Clinical Sciences, Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden; Swedish Hip Arthroplasty Register, Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - A Eskelinen
- Coxa Hospital for Joint Replacement, Tampere, Finland.
| | - A B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark.
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Yu TH, Tung YC, Chung KP. Does Categorization Method Matter in Exploring Volume-Outcome Relation? A Multiple Categorization Methods Comparison in Coronary Artery Bypass Graft Surgery Surgical Site Infection. Surg Infect (Larchmt) 2015; 16:466-72. [PMID: 26069929 DOI: 10.1089/sur.2014.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Volume-infection relation studies have been published for high-risk surgical procedures, although the conclusions remain controversial. Inconsistent results may be caused by inconsistent categorization methods, the definitions of service volume, and different statistical approaches. The purpose of this study was to examine whether a relation exists between provider volume and coronary artery bypass graft (CABG) surgical site infection (SSI) using different categorization methods. METHODS A population-based cross-sectional multi-level study was conducted. A total of 10,405 patients who received CABG surgery between 2006 and 2008 in Taiwan were recruited. The outcome of interest was surgical site infection for CABG surgery. The associations among several patient, surgeon, and hospital characteristics was examined. The definition of surgeons' and hospitals' service volume was the cumulative CABG service volumes in the previous year for each CABG operation and categorized by three types of approaches: Continuous, quartile, and k-means clustering. RESULTS The results of multi-level mixed effects modeling showed that hospital volume had no association with SSI. Although the relation between surgeon volume and surgical site infection was negative, it was inconsistent among the different categorization methods. CONCLUSIONS Categorization of service volume is an important issue in volume-infection study. The findings of the current study suggest that different categorization methods might influence the relation between volume and SSI. The selection of an optimal cutoff point should be taken into account for future research.
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Affiliation(s)
- Tsung-Hsien Yu
- Institute of Health Policy and Management, National Taiwan University , Taipei, Taiwan
| | - Yu-Chi Tung
- Institute of Health Policy and Management, National Taiwan University , Taipei, Taiwan
| | - Kuo-Piao Chung
- Institute of Health Policy and Management, National Taiwan University , Taipei, Taiwan
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Which Kind of Provider's Operation Volumes Matters? Associations between CABG Surgical Site Infection Risk and Hospital and Surgeon Operation Volumes among Medical Centers in Taiwan. PLoS One 2015; 10:e0129178. [PMID: 26053035 PMCID: PMC4459823 DOI: 10.1371/journal.pone.0129178] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 05/05/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Volume-infection relationships have been examined for high-risk surgical procedures, but the conclusions remain controversial. The inconsistency might be due to inaccurate identification of cases of infection and different methods of categorizing service volumes. This study takes coronary artery bypass graft (CABG) surgical site infections (SSIs) as an example to examine whether a relationship exists between operation volumes and SSIs, when different SSIs case identification, definitions and categorization methods of operation volumes were implemented. METHODS A population-based cross-sectional multilevel study was conducted. A total of 7,007 patients who received CABG surgery between 2006 and 2008 from 19 medical centers in Taiwan were recruited. SSIs associated with CABG surgery were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) codes and a Classification and Regression Trees (CART) model. Two definitions of surgeon and hospital operation volumes were used: (1) the cumulative CABG operation volumes within the study period; and (2) the cumulative CABG operation volumes in the previous one year before each CABG surgery. Operation volumes were further treated in three different ways: (1) a continuous variable; (2) a categorical variable based on the quartile; and (3) a data-driven categorical variable based on k-means clustering algorithm. Furthermore, subgroup analysis for comorbidities was also conducted. RESULTS This study showed that hospital volumes were not significantly associated with SSIs, no matter which definitions or categorization methods of operation volume, or SSIs case identification approaches were used. On the contrary, the relationships between surgeon's volumes varied. Most of the models demonstrated that the low-volume surgeons had higher risk than high-volume surgeons. CONCLUSION Surgeon volumes were more important than hospital volumes in exploring the relationship between CABG operation volumes and SSIs in Taiwan. However, the relationships were not robust. Definitions and categorization methods of operation volume and correct identification of SSIs are important issues for future research.
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Elings J, Hoogeboom TJ, van der Sluis G, van Meeteren NLU. What preoperative patient-related factors predict inpatient recovery of physical functioning and length of stay after total hip arthroplasty? A systematic review. Clin Rehabil 2014; 29:477-92. [DOI: 10.1177/0269215514545349] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 07/05/2014] [Indexed: 02/03/2023]
Abstract
Objective: To identify the preoperative patient-related characteristics predicting inpatient recovery of functioning and/or length of hospital stay after elective primary total hip arthroplasty. Design: A search was conducted of the electronic databases MEDLINE, EMBASE and CINAHL from inception through April 2014. Observational studies were selected for systematic review if they identified clinically relevant preoperative prognostic factors and reported an association between inpatient recovery of physical functioning and/or length of hospital stay. Study participants were adults undergoing an elective primary total hip arthroplasty. Results: Fourteen studies were included, a total of 199,410 individual total hip arthroplasty procedures. Two studies investigated inpatient recovery of physical functioning, no strong level of evidence was found for a relationship between functional recovery and any of the preoperative predictors. Twelve studies investigated the length of hospital stay and reported 19 preoperative prognostic factors. A strong level of evidence suggested that higher scores on the American Society of Anaesthesiologists assessment (OR 3.34 to 6.22, +0.20 days), increased number of comorbidities (RR of 1.10, +0.59 to 1.61 days), presence of heart disease, (RR of 1.59, +0.26 days), and presence of lung disease (RR of 1.30, +0.34 days) were associated with longer lengths of hospital stay following total hip arthroplasty. Conclusion: For the prediction of inpatient recovery of physical functioning no factors with a strong level of evidence were found. For length of stay there was a strong level of evidence for the American Society of Anaesthesiologists score, number of comorbidities, and presence of heart or lung disease.
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Affiliation(s)
- J Elings
- Department of Physical Therapy, Diakonessenhuis Hospital, Utrecht, the Netherlands
- Department of Epidemiology, Maastricht University Medical Centre, the Netherlands
| | - TJ Hoogeboom
- Department of Epidemiology, Maastricht University Medical Centre, the Netherlands
- Centre for Care Technology Research (CCTR), Maastricht, the Netherlands
| | - G van der Sluis
- Department of Epidemiology, Maastricht University Medical Centre, the Netherlands
- Department of Physical Therapy, Nij Smellinghe, Drachten, the Netherlands
| | - NLU van Meeteren
- Department of Epidemiology, Maastricht University Medical Centre, the Netherlands
- Centre for Care Technology Research (CCTR), Maastricht, the Netherlands
- TNO Healthy Living, Leiden, the Netherlands
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The association between comorbidity and length of hospital stay and costs in total hip arthroplasty patients: a systematic review. J Arthroplasty 2014; 29:1009-14. [PMID: 24287128 DOI: 10.1016/j.arth.2013.10.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 10/03/2013] [Accepted: 10/06/2013] [Indexed: 02/01/2023] Open
Abstract
We performed a systematic review on the relationship between comorbidity and length of hospital stay (LOS) and hospital costs (HC). Electronic databases were systematically searched for relevant studies, conducting methodological quality assessment and best-evidence synthesis: 317 articles were identified, 10 of which fit the inclusion criteria; nine studies determined the relationship between comorbidity and LOS, with eight reporting a positive correlation; five studies were considered to be of high quality, four of which found a positive correlation; two studies analyzed the relationship between comorbidity and HC and reported significantly higher HC for patients with comorbidities, and were considered to be of high quality. In conclusion, there is limited evidence that patient comorbidity has a positive correlation with LOS and HC.
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Singh JA, Lewallen DG. Medical comorbidity is associated with persistent index hip pain after total hip arthroplasty. PAIN MEDICINE 2013; 14:1222-9. [PMID: 23742141 DOI: 10.1111/pme.12153] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To characterize whether medical comorbidity predicts persistent moderate-severe pain after total hip arthroplasty (THA). METHODS We analyzed the prospectively collected data from the Mayo Clinic Total Joint Registry for patients who underwent primary or revision THA between 1993 and 2005. Using multivariable-adjusted logistic regression analyses, we examined whether certain medical comorbidities were associated with persistent moderate-severe hip pain 2 or 5 years after primary or revision THA. Odds ratios (ORs), along with 95% confidence intervals (CIs) and P value, are presented. RESULTS The primary THA cohort consisted of 5,707 THAs and 3,289 THAs at 2 and 5 years, and revision THA, 2,687 and 1,627 THAs, respectively. In multivariable-adjusted logistic regression models, in the primary THA cohort, renal disease was associated with lower odds of moderate-severe hip pain (OR 0.6; 95% CI 0.3, 1.0) at 2 years. None of the comorbidities were significantly associated at 5 years. In the revision THA cohort, heart disease was significantly associated with higher risk (OR 1.7; 95% CI 1.1, 2.6) at 2 years and connective tissue disease with lower risk (OR 0.5; 95% CI 0.3, 0.9) of moderate-severe hip pain at 5-year follow-up. CONCLUSION This study identified new correlates of moderate-severe hip pain after primary or revision THA, a much-feared outcome of hip arthroplasty. Patients with these comorbidities should be informed regarding the risk of moderate-severe index hip pain, so that they can have a fully informed consent and realistic expectations.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service and Center for Surgical Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, Alabama, USA.
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Body mass index as predictor of health-related quality-of-life changes after total hip arthroplasty: a cross-over study. J Arthroplasty 2013; 28:666-70. [PMID: 23142451 DOI: 10.1016/j.arth.2012.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 06/20/2012] [Accepted: 07/10/2012] [Indexed: 02/01/2023] Open
Abstract
The objective of this study was to examine the contribution of patient weight and other preoperative variables to improvements in the general physical health of patients undergoing total hip arthroplasty (THA). Data were prospectively collected on 63 THA patients (28 males and 35 females). The primary outcome measure was the improvement in general health (Short Form-12 Health Survey questionnaire) at three months post-THA. Patients with body mass index >28kg/m(2) showed greater improvements in function and in the physical component of general health after THA. Stepwise regression analyses revealed that the BMI and WOMAC general index were independent and significant predictors of physical function and together explained 34.2% of the variance in physical function scores. These findings suggest that the body mass index before surgery and improvements in hip function are relevant contributors to post-THA improvements in general health.
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Singh JA, Lewallen DG. Medical and psychological comorbidity predicts poor pain outcomes after total knee arthroplasty. Rheumatology (Oxford) 2013; 52:916-23. [PMID: 23325037 DOI: 10.1093/rheumatology/kes402] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To study comorbidity correlates of moderate to severe pain after total knee arthroplasty (TKA). METHODS We analysed prospectively collected Total Joint Registry data to examine whether medical (heart disease, peripheral vascular disease, renal disease, chronic obstructive pulmonary disease, diabetes and CTD) and psychological (anxiety and depression) comorbidity is associated with moderate to severe pain after primary or revision TKA. Multivariable-adjusted logistic regression simultaneously adjusted for all comorbidities, age, sex, BMI, underlying diagnosis, American Society of Anesthesiologist (ASA) class, distance from medical centre and implant fixation (only for primary TKA) was used to analyse primary and revision TKA separately. RESULTS The primary TKA cohort consisted of 7139 and 4234 TKAs (response rates 65% and 57%) and the revision TKA cohort consisted of 1533 and 881 TKAs at 2 and 5 years (response rates 57% and 48%), respectively. In the primary TKA cohort, anxiety was associated with 1.4 higher odds (95% CI 1.0, 2.0) of moderate to severe index knee pain at 2 years; at 5 years, heart disease (OR 1.7; 95% CI 1.1, 2.6), depression (OR 1.7; 95% CI 1.1, 2.5) and anxiety (OR 1.9; 95% CI 1.2, 3.1) were significantly associated with moderate to severe pain. For revision TKA, CTD (OR 0.5; 95% CI 0.2, 0.9) and depression (OR 1.8; 95% CI 1.1, 3.1) were significantly associated with moderate to severe pain. CONCLUSION This study identified medical and psychological comorbidity risk factors for moderate to severe pain after primary and revision TKA. This information can be used to provide realistic outcome expectations for patients before undergoing primary or revision TKA.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service and Center for Surgical Medical Acute Care Research and Transitions, Birmingham VA Medical Center, AL, USA.
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