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Wolf M, Goldmann A, Tsitlakidis S, Renkawitz T, Maier MW, Bülhoff M. High comorbidity burden and low incidence of adverse events in primary shoulder arthroplasty in tertiary care at a university hospital. J Orthop 2024; 58:82-89. [PMID: 39070113 PMCID: PMC11269281 DOI: 10.1016/j.jor.2024.06.040] [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: 05/29/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
Background Reducing perioperative risk is in the focus of primary arthroplasty caregivers. Primary shoulder arthroplasty patients are considered among those with the lowest perioperative risk. Nonetheless, in tertiary care centres and university settings patients with significant comorbidities are being treated. It remains unclear whether the overall comorbidity burden is truly higher and if this results in an increased frequency of adverse events (AE). As a result, we conducted a study to assess the comorbidity burden and the frequency of major perioperative adverse events and predictive factors following primary shoulder arthroplasty in the university setting. Methods A retrospective cohort analysis was conducted on patients undergoing primary shoulder arthroplasty for a non-trauma, non-tumour indication from January 1st, 2014 through December 31st, 2018. Administrative data were recorded to assess comorbidity burden and revision surgery within the first postoperative year. Major adverse events were routinely recorded on a weekly basis by the treating physicians. Descriptive and comparative statistical analyses were performed. The cohort was compared against a large North American sample. Results Of 386 patients who underwent 400 primary shoulder arthroplasties 14 (3.5 %) experienced adverse events. While AE were distributed equally among anatomical and reverse shoulder arthroplasties, no adverse event was recorded in the 34 hemiarthroplasty patients. The cohort showed an increased comorbidity burden in international comparison. Peptic ulcer disease was significantly associated with AE, while mild liver disease experienced a trend towards AE. Conclusion We found an increased comorbidity burden and a low rate of AE for primary shoulder arthroplasty in a tertiary care and university setting. The distinct role of peptic ulcer disease in this cohort and the trend in mild liver disease merit further investigation in larger samples. The findings underscore the importance of perioperative risk assessment and management. Level of evidence III, retrospective cohort study.
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Affiliation(s)
- Matthias Wolf
- Heidelberg University Hospital, Orthopaedic University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Albert Goldmann
- Heidelberg University Hospital, Orthopaedic University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Stefanos Tsitlakidis
- Heidelberg University Hospital, Orthopaedic University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Tobias Renkawitz
- Heidelberg University Hospital, Orthopaedic University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Michael W. Maier
- Swabian Joint Center Backnang, Neckarsulmer Str. 5, 71522, Backnang, Germany
| | - Matthias Bülhoff
- Heidelberg University Hospital, Orthopaedic University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
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Richard RD, Pesante BD, Parry JA, Mauffrey C. The Effect of Adverse Events on Orthopaedic Surgeons: A Review. J Am Acad Orthop Surg 2024; 32:771-776. [PMID: 39019003 DOI: 10.5435/jaaos-d-23-01205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/16/2024] [Indexed: 07/19/2024] Open
Abstract
The purpose of this review was to evaluate the effect of adverse events (AEs) on orthopaedic surgeons, illustrate common ways orthopaedic surgeons deal with AEs, and describe solutions to reduce the negative effect of AEs and prevent them from recurring. AEs are common in orthopaedic surgery and increase the risk of depression, anxiety, and suicide. Orthopaedic surgeons may experience negative effects after AEs even when they are not at fault. AEs are linked to moral injury, second victim syndrome, burnout, and disruptive physician behaviors. Many surgeons deal with AEs in isolation out of fear of a negative effect on their professional reputation, potentially leading to increased psychological distress and unhealthy coping mechanisms. Healthy ways to address AEs and improve the well-being of surgeons include destigmatizing psychological stress after AEs and creating a culture of receptivity and peer support.
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Affiliation(s)
- Raveesh D Richard
- From the Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
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Rampersaud YR, Sundararajan K, Docter S, Perruccio AV, Gandhi R, Adams D, Briggs N, Davey JR, Fehlings M, Lewis SJ, Magtoto R, Massicotte E, Sarro A, Syed K, Mahomed NN, Veillette C. Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study. BMC Health Serv Res 2023; 23:1150. [PMID: 37880706 PMCID: PMC10598977 DOI: 10.1186/s12913-023-10055-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 09/23/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries. METHODS Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors. RESULTS The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs. CONCLUSIONS This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.
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Affiliation(s)
- Y Raja Rampersaud
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada.
- Krembil Research Institute, University Health Network, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada.
| | - Kala Sundararajan
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Shgufta Docter
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
| | - Anthony V Perruccio
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Rajiv Gandhi
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Diana Adams
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
| | - Natasha Briggs
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
| | - J Rod Davey
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael Fehlings
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Stephen J Lewis
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Rosalie Magtoto
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Eric Massicotte
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Angela Sarro
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Khalid Syed
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nizar N Mahomed
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christian Veillette
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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Zusman NL, Woelber E, McKibben NS, Gallacher DM, Thompson AR, Friess DM, El Naga AN, Working ZM. Acetabular fracture pattern is altered by pre-injury sacroiliac joint autofusion. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03588-w. [PMID: 37300591 DOI: 10.1007/s00590-023-03588-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Acetabular fracture shape is determined by the direction of force applied. We perceive an anecdotally observed connection between pre-existing autofused sacroiliac joints (aSIJ) and high anterior column (HAC) injuries. The purpose of this study was to compare variations in acetabular fracture patterns sustained in patients with and without pre-injury sacroiliac (SI) joint autofusion. METHODS All adult patients receiving unilateral acetabular fixation (level 1 academic trauma; 2008-2018) were reviewed. Injury radiographs and CT scans were reviewed for fracture patterns and pre-existing aSIJ. Fracture types were subgrouped presence of HAC injury (includes anterior column (AC), anterior column posterior hemitransverse (ACPHT), or associated both column (ABC)). ANALYSIS Logistic regression determined the association between aSIJ and HAC. RESULTS A total of 371 patients received unilateral acetabular fixation (2008-2018); 61 (16%) demonstrated CT evidence of idiopathic aSIJ. These patients were older (64.1 vs. 47.4, p < 0.01), more likely to be male (95% vs. 71%, p < 0.01), less likely to be smokers (19.0% vs. 44.8%, p < 0.01), and were injured from lower energy mechanisms (21.3% vs. 8.4%, p = 0.01). The most common patterns with autofusion were ACPHT (n = 13, 21%) and ABC (n = 25, 41%). Autofusion was associated with greater odds of patterns involving a high anterior column injury (ABC, ACPHT, or isolated anterior column; OR = 4.97, p < 0.01). After adjusting for age, mechanism, and body mass index, the connection between autofusion and high anterior column injuries remained significant (OR = 2.60, p = 0.01). CONCLUSIONS SI joint autofusion appears to change mode of failure in acetabular injuries; a more rigid posterior ring may precipitate a high anterior column injury. LEVEL OF EVIDENCE Prognostic level III.
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Affiliation(s)
- Natalie L Zusman
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Erik Woelber
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Natasha S McKibben
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239, USA
| | - David M Gallacher
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Austin R Thompson
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Darin M Friess
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Ashraf N El Naga
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Zachary M Working
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239, USA.
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Characterizing Single-star Negative Online Reviews of Orthopaedic Trauma Association Members. J Am Acad Orthop Surg 2023; 31:397-404. [PMID: 36727955 DOI: 10.5435/jaaos-d-22-00631] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/14/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION The purpose of this study was to characterize factors that contribute to 1-star negative reviews regarding orthopaedic trauma surgeons. METHODS A search was done for Orthopaedic Trauma Association members on Yelp.com, Healthgrade.com, and Vitals.com in New York, Boston, San Francisco, Los Angeles, Dallas, Phoenix, Seattle, Baltimore, Denver, Houston, Philadelphia, and Washington, DC. All single-star reviews (out of a possible 5 stars) were included in this study. Reviews were categorized as either clinical or nonclinical and then further subcategorized. Categorical variables were analyzed using a chi-square test. The rate ratio (the ratio of the rate for nonsurgical divided by surgical reviews) was determined for each category. RESULTS Two hundred eighty-eight single-star reviews were included in the study, comprising 655 total complaints. Of all complaints, 274 (41.8%) were clinically related and 381 (58.2%) were nonclinical. Of the 288 single-star reviews, 96 (33.3%) were from surgically treated patients and 192 (66.7%) were from nonsurgical patients. Most complaints were in reference to nonclinical aspects of care such as physician bedside manner (173 reviews, 60%), not enough time spent with provider (58 reviews, 20%), and wait time (42 complaints, 15%). The most common clinical complaints were for complication (61 reviews, 21%), disagree with decision/plan (49 reviews, 17%), and uncontrolled pain (45 reviews, 16%). Surgical patients had a significantly higher rate of clinical complaints than nonsurgical patients (1.57 vs. 0.64 clinical complaints per review, P < 0.001). Nonsurgical patients had a significantly higher rate of nonclinical complaints than surgical patients (1.43 vs. 1.10 nonclinical complaints per review, P < 0.001). DISCUSSION Most 1-star reviews referenced a nonclinical aspect of care with a physician's bedside manner being the most common complaint. Surgical patients were markedly more likely to reference a clinical aspect of care, such as complications or misdiagnosis compared with nonsurgical patients, who more commonly referenced nonclinical aspects of care.
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Suneja N, Kong RM, Tiburzi HA, Shah NV, von Keudell AG, Harris MB, Saleh A. Racial Differences in Orthopedic Trauma Surgery. Orthopedics 2022; 45:71-76. [PMID: 35021034 DOI: 10.3928/01477447-20220105-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].
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Cwalina TB, Jella TK, Acuña AJ, Samuel LT, Kamath AF. How Did Orthopaedic Surgeons Perform in the 2018 Centers for Medicaid & Medicare Services Merit-based Incentive Payment System? Clin Orthop Relat Res 2022; 480:8-22. [PMID: 34543249 PMCID: PMC8673991 DOI: 10.1097/corr.0000000000001981] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/27/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Merit-based Incentive Payment System (MIPS) is the latest value-based payment program implemented by the Centers for Medicare & Medicaid Services. As performance-based bonuses and penalties continue to rise in magnitude, it is essential to evaluate this program's ability to achieve its core objectives of quality improvement, cost reduction, and competition around clinically meaningful outcomes. QUESTIONS/PURPOSES We asked the following: (1) How do orthopaedic surgeons differ on the MIPS compared with surgeons in other specialties, both in terms of the MIPS scores and bonuses that derive from them? (2) What features of surgeons and practices are associated with receiving penalties based on the MIPS? (3) What features of surgeons and practices are associated with receiving a perfect score of 100 based on the MIPS? METHODS Scores from the 2018 MIPS reporting period were linked to physician demographic and practice-based information using the Medicare Part B Provider Utilization and Payment File, the National Plan and Provider Enumeration System Data (NPPES), and National Physician Compare Database. For all orthopaedic surgeons identified within the Physician Compare Database, there were 15,210 MIPS scores identified, representing a 72% (15,210 of 21,124) participation rate in the 2018 MIPS. Those participating in the MIPS receive a final score (0 to 100, with 100 being a perfect score) based on a weighted calculation of performance metrics across four domains: quality, promoting interoperability, improvement activities, and costs. In 2018, orthopaedic surgeons had an overall mean ± SD score of 87 ± 21. From these scores, payment adjustments are determined in the following manner: scores less than 15 received a maximum penalty adjustment of -5% ("penalty"), scores equal to 15 did not receive an adjustment ("neutral"), scores between 15 and 70 received a positive adjustment ("positive"), and scores above 70 (maximum 100) received both a positive adjustment and an additional exceptional performance adjustment with a maximum adjustment of +5% ("bonus"). Adjustments among orthopaedic surgeons were compared across various demographic and practice characteristics. Both the mean MIPS score and the resulting payment adjustments were compared with a group of surgeons in other subspecialties. Finally, multivariable logistic regression models were generated to identify which variables were associated with increased odds of receiving a penalty as well as a perfect score of 100. RESULTS Compared with surgeons in other specialties, orthopaedic surgeons' mean MIPS score was 4.8 (95% CI 4.3 to 5.2; p < 0.001) points lower. From this difference, a lower proportion of orthopaedic surgeons received bonuses (-5.0% [95% CI -5.6 to -4.3]; p < 0.001), and a greater proportion received penalties (+0.5% [95% CI 0.2 to 0.8]; p < 0.001) and positive adjustments (+4.6% [95% CI 6.1 to 10.7]; p < 0.001) compared with surgeons in other specialties. After controlling for potentially confounding variables such as gender, years in practice, and practice setting, small (1 to 49 members) group size (adjusted odds ratio 22.2 [95% CI 8.17 to 60.3]; p < 0.001) and higher Hierarchical Condition Category (HCC) scores (aOR 2.32 [95% CI 1.35 to 4.01]; p = 0.002) were associated with increased odds of a penalty. Also, after controlling for potential confounding, we found that reporting through an alternative payment model (aOR 28.7 [95% CI 24.0 to 34.3]; p < 0.001) was associated with increased odds of a perfect score, whereas small practice size (1 to 49 members) (aOR 0.35 [95% CI 0.31 to 0.39]; p < 0.001), a high patient volume (greater than 500 Medicare patients) (aOR 0.82 [95% CI 0.70 to 0.95]; p = 0.01), and higher HCC score (aOR 0.79 [95% Cl 0.66 to 0.93]; p = 0.006) were associated with decreased odds of a perfect MIPS score. CONCLUSION Collectively, orthopaedic surgeons performed well in the second year of the MIPS, with 87% earning bonus payments. Among participating orthopaedic surgeons, individual reporting affiliation, small practice size, and more medically complex patient populations were associated with higher odds of receiving penalties and lower odds of earning a perfect score. Based on these findings, we recommend that individuals and orthopaedic surgeons in small group practices strive to forge partnerships with larger hospital practices with adequate ancillary staff to support quality reporting initiatives. Such partnerships may help relieve surgeons of growing administrative obligations and allow for maintained focus on direct patient care activities. Policymakers should aim to produce a shortened panel of performance measures to ensure more standardized comparison and less time and energy diverted from established clinical workflows. The current MIPS scoring methodology should also be amended with a complexity modifier to ensure fair evaluation of surgeons practicing in the safety net setting, or those treating patients with a high comorbidity burden. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Thomas B. Cwalina
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tarun K. Jella
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alexander J. Acuña
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Linsen T. Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Atul F. Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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A Comparison of Acute Complications and Mortality Between Geriatric Knee and Hip Fractures: A Matched Cohort Study. J Am Acad Orthop Surg 2021; 29:929-936. [PMID: 34570742 DOI: 10.5435/jaaos-d-20-00090] [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: 02/07/2020] [Accepted: 10/02/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION To compare acute complication and mortality rates for operatively treated, closed, isolated, low-energy geriatric knee fractures (distal femur [DFF] or tibial plateau [TPF]) with hip fractures (HFs). METHODS This is a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients ≥ 70 years from 2011 to 2016 who underwent surgery for DFF, TPF, or HF. We recorded patient demographics, functional status, complications, and mortality. We matched DFF:TPF:HF patients on a 1:1:10 ratio based on age, sex, body mass index, baseline functional status, and comorbidity. We used the chi square, Fisher exact, and Mann Whitney U tests to compare unadjusted differences between groups and multivariable logistic regression to compare the risk of complications, readmission, or death while adjusting for relevant covariates. RESULTS When compared with HF, patients in the DFF and TPF groups had longer length of stay and time to index surgery and were more likely to be discharged home. The rate of deep vein thrombosis was significantly higher in the TPF group (TPF = 3.9%, DFF = 1.3%, and HF = 1.2%, P = 0.005). CONCLUSION Geriatric knee fractures pose a similar risk of acute complications, mortality, and readmission compared with patients with HF. Future studies investigating strategies to decrease risk in this patient cohort are warranted. LEVEL OF EVIDENCE Therapeutic Level III.
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Ortner J, Vives A, Moya D, Torres M, Grau N, Farrús X, Manzanera R, Mira JJ. Frequency of outpatient care adverse events in an occupational mutual insurance company in Spain. J Healthc Qual Res 2021; 36:340-344. [PMID: 34246648 DOI: 10.1016/j.jhqr.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/15/2021] [Accepted: 05/23/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Occupational mutual insurance companies (OMICs), in collaboration with the Spanish Social Security System, provide healthcare and manage the economic benefits for the workers in Spain. They have ambulatory care centers that attend outpatient trauma pathology, although most of the studies published have focused on surgical and hospital activity. The aim of this study was to detect adverse events (AEs) in outpatient trauma care in the context of an OMIC. METHODS A cohort study designed to identify harmful safety incidents (adverse events, AEs) in 2017 was conducted. A random sample of 313 medical records among patients who were visited more than 3 medical and nursing attendances during their outpatient process. The AEs detected were classified according to category, severity and preventability. RESULTS We identified 48 AEs (15.3% of medical records, 95% CI 11.3-19.3), most of them procedure-related, while 27 (56.2%) were preventable and 46 mild (95.8%). CONCLUSIONS The AEs identified are double than those found in primary care general consultations in Spain and are close to the lower range of studies on surgical AEs in traumatology and orthopedics. Preventable AEs were within expected limits. Over half of AEs are preventable, within that group, the mild AEs have an increased rate of preventability. These results highlight the relevance of research of patient safety in the outpatient care of trauma and orthopaedic procedures in an OMIC for patient safety and contribute to introduce improvements in outpatient care.
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Affiliation(s)
- J Ortner
- MC Mutual, C/ Provença, 321, 08037 Barcelona, Spain.
| | - A Vives
- MC Mutual, C/ Provença, 321, 08037 Barcelona, Spain
| | - D Moya
- MC Mutual, C/ Provença, 321, 08037 Barcelona, Spain
| | - M Torres
- MC Mutual, C/ Provença, 321, 08037 Barcelona, Spain
| | - N Grau
- MC Mutual, C/ Provença, 321, 08037 Barcelona, Spain
| | - X Farrús
- MC Mutual, C/ Provença, 321, 08037 Barcelona, Spain
| | - R Manzanera
- MC Mutual, C/ Provença, 321, 08037 Barcelona, Spain
| | - J J Mira
- Universidad Miguel Hernández, Avinguda de la Universitat d'Elx, s/n, 03202 Elche, Alicante, Spain; Departamento de Salud de Alicante-Sant Joan, Alicante, Spain
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Zhao R, Ding R, Zhang Q. What Are the Risk Factors for Surgical Site Infection in HIV-Positive Patients Receiving Open Reduction and Internal Fixation of Traumatic Limb Fractures? A Retrospective Cohort Study. AIDS Res Hum Retroviruses 2021; 37:551-556. [PMID: 33386058 DOI: 10.1089/aid.2020.0184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A lack of studies analyze risk factors associated with surgical site infection (SSI) in human immunodeficiency virus (HIV)-positive patients with trauma undergoing orthopedic surgery. We questioned, (1) "What is the proportion of SSI in HIV-positive patients receiving open reduction and internal fixation (ORIF) of traumatic limb fractures?" and (2) "What are the independent risk factors for SSI of HIV-positive patients with traumatic limb fractures who received ORIF?" A retrospective study was performed in our institution from May 2011 to December 2019. A total of 246 patients were enrolled. Data of HIV-positive adult patients with traumatic limb fractures treated by ORIF were extracted from the electronic medical records, including the demographic information, characteristics of fractures, treatment-related variables, and indexes of laboratory examination. Multivariable logistic regression was used to identify independent predictors of SSI. A total of 26 patients developed SSI in this study, the overall proportion was 10.6% [95% confidence interval (CI) = 7.2%-15.3%]. Among them, 18 cases (7.3%) suffered from superficial SSI and 8 cases (3.3%) had the deep SSI. Independent predictors of SSI identified by multivariable logistic regression analysis were CD4+ T-lymphocyte count (adjusted odds ratio per 100/μL increase = 0.55; 95% CI = 0.37-0.81; p = .002) and albumin (adjusted odds ratio per 5 g/liter increase = 0.50; 95% CI = 0.30-0.81; p = .003). We recommend that orthopedic surgeons assess immunosuppression and nutritional status of HIV-positive patients rigorously and optimize the perioperative strategy of supplementary to reduce the risk of SSI.
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Affiliation(s)
- Rugang Zhao
- Department of Orthopedic, Beijing Ditan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Emerging Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Rui Ding
- Center of Liver Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qiang Zhang
- Department of Orthopedic, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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Fennessy J, Wick J, Scott F, Roberto R, Javidan Y, Klineberg E. The Utility of Magnetic Resonance Imaging for Detecting Unstable Cervical Spine Injuries in the Neurologically Intact Traumatized Patient Following Negative Computed Tomography Imaging. Int J Spine Surg 2021; 14:901-907. [PMID: 33560249 DOI: 10.14444/7138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Neurologically intact blunt trauma patients with persistent neck pain and negative computed tomography (CT) imaging frequently undergo magnetic resonance imaging (MRI) for evaluation of occult cervical spine injury. There is a paucity of data to support or refute this practice. This study was therefore performed to evaluate the utility of cervical spine MRI in neurologically intact blunt trauma patients with negative CT imaging. METHODS A retrospective review was performed of all neurologically intact blunt trauma patients presenting to a level 1 trauma center from 2005 to 2015 with persistent neck pain and negative CT imaging. The proportion of patients with positive MRI findings, subsequent treatment, and time required to obtain MRI results was evaluated. RESULTS Of 223 patients meeting inclusion criteria, 11 had positive MRI findings; however, no patients were found to have unstable injuries requiring surgical treatment. The process for a complete evaluation of unstable cervical spine injury from the time of obtaining a CT scan was 19 hours and 43 minutes. CONCLUSIONS Eleven patients had positive MRI findings, yet these findings did not alter treatment. In contrast, the time required to obtain MRI results may substantially delay patient care. LEVEL OF EVIDENCE IV (retrospective case series) CLINICAL RELEVANCE: Our results demonstrate that MRI has limited utility in neurologically intact blunt trauma patients with negative CT imaging.
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Affiliation(s)
| | - Joseph Wick
- University of California, Davis, Sacramento, California
| | - Fiona Scott
- University of California, Davis, Sacramento, California
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Abstract
As we transition from volume-based to value-based health care, orthopedic surgeons must understand the role of outcomes in measuring value. Patient-reported outcomes (PROs) offer a number of advantages in orthopedic trauma compared with traditional clinical and radiographic results while also being an important indicator of the patient's perception of their condition. Patient-Reported Outcomes Measurement Information System, developed and funded by the National Institutes of Health, has a number of features that make PRO date collection less burdensome for providers and patients. Patient-specific factors, including comorbidities, mental health, social support, and preinjury function need to be accounted for in our assessment, because all of these factors have demonstrated an impact on outcomes. Orthopedic surgeons should be aware of how they can transition their practice in an era of value-based health care in a manner that will benefit their patients and provide insight into their own clinical practice. Prospective collection of PROs is no longer limited to academic surgeons conducting research, and all orthopedic surgeons should consider incorporating PROs into their daily clinical practice. Orthopedic surgeons must maintain an active role in the development of policies and reimbursement models to advocate for and serve our patients.
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Githens T, DeBaun MR, Campbell ST, Wu EJ, Goodnough LH, Lichstein P, Painter C, Krygier JE, Bishop J, Gardner MJ. Rates of Perioperative Complications Among Patients Undergoing Orthopedic Trauma Surgery Despite Having Positive Results for Methamphetamine. Orthopedics 2019; 42:192-196. [PMID: 31136677 DOI: 10.3928/01477447-20190523-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/16/2019] [Indexed: 02/03/2023]
Abstract
The burden of psychosocial problems, including substance abuse, is high among trauma patients. Use of illicit substances is often noted during urine toxicology screening on admission and can delay surgery because of concerns for an interaction with anesthesia. Methamphetamine theoretically has potential to increase perioperative anesthetic risks. However, the authors are unaware of any studies documenting increased rates of cardiovascular complications in the perioperative period among orthopedic trauma patients. This study sought to determine the rate of cardiovascular complications in these patients. The authors reviewed the medical records of all patients between 2013 and 2018 who underwent orthopedic trauma surgery at two level I trauma centers in the setting of a methamphetamine-positive urine toxicology screening prior to surgery. Information on demographics, injury, type of surgical intervention, and incidence of perioperative cardiovascular and overall medical complications prior to discharge was recorded. Ninety-four patients were included in the study (mean age, 44 years; range, 16-78 years). Twenty-six (28%) patients had multiple injuries. Thirteen (14%) patients had debridement and/or provisional stabilization of an open or unstable fracture, 18 (19%) had treatment for an infection, and 63 (67%) had definitive fracture surgery. The overall rates of perioperative cardiovascular complications and perioperative medical complications were 2.1% and 3.2%, respectively. This study provides both a baseline understanding of the complication rate for methamphetamine-positive orthopedic trauma patients during general anesthesia and justification for larger multicenter studies to further investigate this topic. [Orthopedics. 2019; 42(4):192-196.].
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Complication rates by surgeon type after open treatment of distal radius fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1543-1547. [PMID: 29922979 DOI: 10.1007/s00590-018-2236-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND In distal radius fracture repair, complications often lead to reoperation and increased cost. We examined the trends and complications in open reduction internal fixation of distal radius fractures across hand specialist and non-hand specialist surgeons. METHODS We examined claims data from the Humana administrative claims database between 2007 and 2016. International Classification of Disease, 9th Edition and Current Procedural Terminology codes were searched related to distal radius fractures repaired by open reduction internal fixation. Patients were filtered based on initial treatment by a hand specialty or non-hand specialty surgeon. Complications were reported within 1 year of surgical treatment in the following distinct categories: non-union, malunion, extensor/flexor tendon repair, CRPS, infection. Descriptive statistics were reported. RESULTS Hand specialists accounted for 182 procedures compared with 7708 procedures by non-hand specialty orthopaedic or general surgeons. There was an increase in the total number of procedures performed by hand specialists across the years of study, with a higher percentage of intra-articular cases completed by hand specialists (80.7%) compared to non-hand specialists (70.1%). Overall, the complication rates of hand specialists (6.5%) were higher than that of non-specialists (4.7%). CONCLUSIONS The results of this study demonstrate a small difference in overall complications for open reduction internal fixation of distal radius fractures by hand specialists in comparison to non-specialists despite treating a higher percentage of intra-articular fractures. Future work controlling for factors unaccounted for in claims-based analyses, such as fracture complexity, patient comorbidities, and surgeon factors are needed. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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McQuillan TJ, Cai LZ, Corcoran-Schwartz I, Weiser TG, Forrester JD. Surgical Site Infections after Open Reduction Internal Fixation for Trauma in Low and Middle Human Development Index Countries: A Systematic Review. Surg Infect (Larchmt) 2018; 19:254-263. [DOI: 10.1089/sur.2017.273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Lawrence Z. Cai
- Stanford University School of Medicine, Stanford, California
| | - Ian Corcoran-Schwartz
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Thomas G. Weiser
- Department of General Surgery, Stanford University, Stanford, California
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, Scotland
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Incidence and Risk Factors for 30-Day Unplanned Readmissions After Elective Posterior Lumbar Fusion. Spine (Phila Pa 1976) 2018; 43:41-48. [PMID: 27031773 DOI: 10.1097/brs.0000000000001586] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To perform a multiinstitutional assessment on the incidence and risk factors for unplanned readmissions following elective posterior lumbar fusion (PLF) surgery. SUMMARY OF BACKGROUND DATA Understanding what may drive rehospitalizations is a necessary step toward higher quality care. Identifying risk factors for unplanned readmission is especially important for elective PLF, which is a common procedure that is known to be associated with significant adverse events. METHODS Adult patients undergoing PLF were identified using current procedure terminology (CPT) from the American College of Surgeons National Surgical Quality Improvement Program. Both descriptive and comparative statistics were performed for patient characteristics, clinical factors, and postoperative complications. Subsequently, a step-wise multivariate logistic regression was employed. RESULTS Of the 2301 patients who met inclusion criteria for this study, 117 were unplanned readmissions (5.1%). These occurred at a mean of 15.9 days (range: 3-30 days) after surgery. The risk-adjusted analysis revealed that bleeding disorder (odds ratio, OR = 2.8, confidence intervals, CI = 1.0-7.6, P = 0.043), insulin dependent diabetes (OR = 2.5, CI = 1.4-4.4, P = 0.004), and total length of stay > 5 days (OR = 1.8, CI = 1.2-2.8, P = 0.009) were independent predictors for unplanned readmission. Significant postoperative complications included wound complications (OR = 27.6, CI = 13.9-54.8, P < 0.0001), pulmonary embolism and/or deep vein thrombosis/thrombophlebitis (OR = 11.9, CI = 5.0-28.5, P < 0.0001), sepsis (OR = 8.5, CI = 2.3-32.1, P = 0.002), and urinary tract infections (OR = 2.4, CI = 0.9-6.9, P = 0.094). CONCLUSION The unplanned readmission rate for patients undergoing PLF was low, but this study's findings of potentially modifiable risk factors suggest that substantial improvement with this quality metric is possible. LEVEL OF EVIDENCE N/A.
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Abstract
BACKGROUND Ankle fractures are among the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency department prior to operative management. In the authors' experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. The aim of this study was to characterize the economic impact of routine inpatient admission of ankle fractures. METHODS A retrospective review of all outpatient ankle fracture surgery performed by a single foot and ankle fellowship-trained surgeon at a tertiary level academic center in 2012 was conducted to identify any patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative management of lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 with regard to national estimates of total volume and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements for diagnosis related group 494 and Medicare outpatient facility reimbursements for Current Procedural Terminology codes 27792, 27814, and 27822 were obtained from the Medicare Acute Inpatient Prospective Pricer and the Medicare Outpatient Pricer Code, respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement, as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision-tree model was derived from probabilities and associated costs and evaluated using modified Monte Carlo simulation. RESULTS Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture open reduction internal fixation cases performed in 2012 by the senior author, 9 patients required admission for polytrauma, medical comorbidities, or age. All 67 outpatients were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. The median length of stay was 3 days for each admission and was associated with an estimated facility reimbursement ranging from $12,920 for Medicare reimbursement of lateral malleolus fractures to $18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were estimated at $4,125 for Medicare patients and $11,459 for private insurance patients. Nationally, annual inpatient admissions accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with $419,327,612 for treatment of these same ankle fractures. CONCLUSION In the authors' experience, closed lateral malleolus, bimalleolar, and trimalleolar fractures were safely and effectively treated on an outpatient basis. Routine perioperative admission of patients sustaining ankle fractures likely results in more than $367 million of excess facility reimbursements annually in the United States. Even if a 25% necessary admission rate were assumed, routine inpatient admission of ankle fractures would result in a $282 million excess economic burden annually in the United States. Although in certain cases, inpatient admission may be necessary, with value-based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding the implications of inpatient stays for ankle fracture surgery can ultimately result in cost savings to the US health care system and patients individually. LEVEL OF EVIDENCE Level III, comparative series.
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Affiliation(s)
- Justin D Stull
- 1 Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Suneel B Bhat
- 1 Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Justin M Kane
- 1 Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Steven M Raikin
- 1 Rothman Institute Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Gagnier JJ, Morgenstern H, Kellam P. A retrospective cohort study of adverse events in patients undergoing orthopaedic surgery. Patient Saf Surg 2017; 11:15. [PMID: 28503200 PMCID: PMC5426038 DOI: 10.1186/s13037-017-0129-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/01/2017] [Indexed: 12/01/2022] Open
Abstract
Background This study’s objective was to identify adverse events following common orthopaedic procedures, and to estimate the incidence rates and risks of these events and their associations with age, sex, and comorbidities. Methods This retrospective cohort study manually reviewed and extracted electronic medical data on the incidence and predictors of adverse events that occurred within 90 days of the 50 most frequent orthopaedic surgeries at an academic hospital in 2010. We also extracted demographic data, baseline comorbidities, and duration of follow-up (≤90 days). Patients were scored on the Charlson Comorbidity Index (CCI) and the Functional Comorbidity Index (FCI). We estimated incidence rates and risks for all events and associations using regression methods. Prolonged pain 42-days post-surgery was treated as a separate outcome. Results We included 1,552 patients; average age was 53.4 years, and 51.7% were female. A total of 1,148 adverse events were identified in 729 patients. The incidence rate of all adverse events was 10 events per 1,000 person-days at risk; 47% of all patients experienced at least one adverse event within 90 days. The most frequent events were prolonged pain (31% of all adverse events) and persistent swelling (7%). We found positive associations between both comorbidity scores and the incidence rate and 90-day risk of all adverse events, excluding pain, adjusting for age and sex (neither of which was associated with adverse events); the association was stronger for the FCI than for the CCI. For total hip arthroplasty (THA) and total knee arthroplasty (TKA), the incidence rate of all adverse events, excluding pain, was positively associated with both comorbidity scores and age; the 90-day risk was positively associate with the FCI score and male sex. The prevalence of prolonged pain at 42 days was greater in patients with higher FCI scores; for THA and TKA only, pain prevalence was greater in those with higher FCI scores and in men. Conclusions Adverse events are frequent following common orthopaedic procedures. The incidence is greatest for patients with more functional comorbidities. For THA and TKA procedures, being male and being older are also associated with a greater incidence of adverse events.
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Affiliation(s)
- Joel J Gagnier
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI USA.,Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Hal Morgenstern
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI USA.,Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI USA.,Department of Urology, Medical School, University of Michigan, Ann Arbor, MI USA
| | - Patrick Kellam
- School of Medicine, University of North Carolina, Chapel Hill, NC USA
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Economic Impact of Nonmodifiable Risk Factors in Orthopaedic Fracture Care: Is Bundled Payment Feasible? J Orthop Trauma 2017; 31:175-179. [PMID: 28212250 DOI: 10.1097/bot.0000000000000742] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether bundled payments are feasible in the orthopaedic fracture setting, and the potential economic implications of this reimbursement structure. DESIGN Prospective. SETTING Multicenter. PATIENTS/PARTICIPANTS Between 2004 and 2014, a total of 23,643 operatively treated patients with fracture and 544,067 patients with total joint arthroplasty (TJA) were identified using the New York State Statewide Planning and Research Cooperative System database. INTERVENTIONS Severity of illness (SOI), hospital charges ($USD), length of stay (LOS; days), and discharge disposition (homebound vs. not) were collected. MAIN OUTCOME MEASUREMENTS Patients were subdivided into groups of minor and severe SOI. Differences in hospital charges, LOS, and discharge disposition were analyzed. Differences in charges, LOS, and discharges were further analyzed based on minor and severe SOI. RESULTS The difference in hospital charge between patients with minor or severe SOI undergoing elective TJA ranged between 153% and 211%. In contrast, patients undergoing fracture surgery exhibited differences ranging from 314% to 489% between minor and severe SOI levels. Similar differences were observed regarding mean hospital LOS and homebound discharge disposition, with patients with fracture demonstrating greater sensitivity to increasing SOI. CONCLUSIONS Although bundled payments may be a viable option for patients undergoing elective TJA, this payment model requires particular attention when applied to fracture care.
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Predicting the post-operative length of stay for the orthopaedic trauma patient. INTERNATIONAL ORTHOPAEDICS 2017; 41:859-868. [DOI: 10.1007/s00264-017-3425-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/05/2017] [Indexed: 11/28/2022]
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Higher Charlson Comorbidity Index Scores Are Associated With Increased Hospital Length of Stay After Lower Extremity Orthopaedic Trauma. J Orthop Trauma 2017; 31:21-26. [PMID: 27611667 DOI: 10.1097/bot.0000000000000701] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to explore the relationship between preoperative Charlson Comorbidity Index (CCI) and postoperative length of stay (LOS) for lower extremity and hip/pelvis orthopaedic trauma patients. DESIGN Retrospective. SETTING Urban level 1 trauma center. PATIENTS/PARTICIPANTS A total of 1561 patients treated for isolated lower extremity and pelvis fractures between 2000 and 2012. INTERVENTIONS Surgical intervention for fractures MAIN OUTCOME MEASUREMENTS:: The main outcome metric was LOS. Negative binomial regression analysis was used to examine the association between CCI and LOS while controlling for significant confounders. RESULTS One thousand five hundred sixty-one patients met the inclusion criteria, 1302 (83.4%) of which had lower extremity injuries and 259 (16.6%) experienced hip/pelvis trauma. A total of 1001 (64.1%) patients presented with a CCI score of 1 and stayed an average of 7.9 days. Patients with a CCI of 3 experienced a mean LOS of 1.2 days longer than patients presenting with a CCI of 1, whereas patients presenting with a CCI score of 5 stayed an average of 4.6 days longer. After controlling for age, race, American Society of Anesthesiologists score, sex, anesthesia type, and anesthesia time, a higher preoperative CCI was found to be associated with longer LOS for patients with lower extremity fractures (Incidence Rate Ratio: 1.04, P = 0.01). No significant association was found between CCI and LOS for patients with hip/pelvic fractures. CONCLUSIONS This study demonstrated the potential utility of the CCI as a predictor of hospital LOS for lower extremity patients; however, the association may be small given the smaller Incidence Rate Ratio value. Further studies are needed to clarify the predictive value of the CCI for different types of orthopaedic injuries. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete.
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Lakomkin N, Sathiyakumar V, Wick B, Shen MS, Jahangir AA, Mir H, Obremskey WT, Dodd AC, Sethi MK. Incidence and predictive risk factors of postoperative sepsis in orthopedic trauma patients. J Orthop Traumatol 2016; 18:151-158. [PMID: 27848054 PMCID: PMC5429254 DOI: 10.1007/s10195-016-0437-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/02/2016] [Indexed: 12/21/2022] Open
Abstract
Background Postoperative sepsis is associated with high mortality and the national costs of septicemia exceed those of any other diagnosis. While numerous studies in the basic orthopedic science literature suggest that traumatic injuries facilitate the development of sepsis, it is currently unclear whether orthopedic trauma patients are at increased risk. The purpose of this study was thus to assess the incidence of sepsis and determine the risk factors that significantly predicted septicemia following orthopedic trauma surgery. Materials and methods 56,336 orthopedic trauma patients treated between 2006 and 2013 were identified in the ACS-NSQIP database. Documentation of postoperative sepsis/septic shock, demographics, surgical variables, and preoperative comorbidities was collected. Chi-squared analyses were used to assess differences in the rates of sepsis between trauma and nontrauma groups. Binary multivariable regressions identified risk factors that significantly predicted the development of postoperative septicemia in orthopedic trauma patients. Results There was a significant difference in the overall rates of both sepsis and septic shock between orthopedic trauma (1.6%) and nontrauma (0.5%) patients (p < 0.001). For orthopedic trauma patients, ventilator use (OR = 15.1, p = 0.002), history of pain at rest (OR = 2.8, p = 0.036), and prior sepsis (OR = 2.6, p < 0.001) were significantly associated with septicemia. Statistically predictive, modifiable comorbidities included hypertension (OR = 2.1, p = 0.003) and the use of corticosteroids (OR = 2.1, p = 0.016). Conclusions There is a significantly greater incidence of postoperative sepsis in the trauma cohort. Clinicians should be aware of these predictive characteristics, may seek to counsel at-risk patients, and should consider addressing modifiable risk factors such as hypertension and corticosteroid use preoperatively. Level of evidence Level III.
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Affiliation(s)
- Nikita Lakomkin
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Vasanth Sathiyakumar
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Brandon Wick
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Michelle S Shen
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - A Alex Jahangir
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Hassan Mir
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - William T Obremskey
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Ashley C Dodd
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Manish K Sethi
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA.
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Schoenfeld AJ. Research Using "Big Data" in Orthopaedic Trauma: A Dynasty of Databases or Finite Research Resource? J Orthop Trauma 2016; 30:225-7. [PMID: 27101160 DOI: 10.1097/bot.0000000000000541] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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