1
|
Sanchez JG, Rancu AL, Diatta FH, Jonnalagadda A, Dhodapkar MM, Knoedler L, Kauke-Navarro M, Grauer JN. Increased Risk of 90-Day Complications in Patients With Fibromyalgia Undergoing Total Shoulder Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202405000-00007. [PMID: 38722914 PMCID: PMC11081627 DOI: 10.5435/jaaosglobal-d-24-00102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/25/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION Anatomic and reverse total shoulder arthroplasties (TSAs) are effective treatment options for end-stage glenohumeral osteoarthritis. Those undergoing TSA may also have fibromyalgia, a musculoskeletal condition. However, the association of fibromyalgia with shorter and longer term outcomes after TSA has not been well characterized. METHODS Patients undergoing TSA for osteoarthritis indications were identified in the PearlDiver M165 database from January 2016 to October 2022. Exclusion criteria included age younger than 18 years, shoulder infection, neoplasm, or trauma within 90 days before surgery, and inactivity in the database within 90 days of surgery. Patients with fibromyalgia were matched in a 1:4 ratio to patients without based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events were compared using univariable and multivariable analyses. Five-year revision-free survival was compared using the log-rank test. RESULTS Of 163,565 TSA patients, fibromyalgia was identified for 9,035 (5.52%). After matching, cohorts of 30,770 non-fibromyalgia patients and 7,738 patients with fibromyalgia were identified. Multivariable analyses demonstrated patients with fibromyalgia were at independently increased odds ratios (ORs) for the following 90-day complications (decreasing OR order): urinary tract infection (OR = 4.49), wound dehiscence (OR = 3.63), pneumonia (OR = 3.46), emergency department visit (OR = 3.45), sepsis (OR = 3.15), surgical site infection (OR = 2.82), cardiac events (OR = 2.72), acute kidney injury (OR = 2.65), deep vein thrombosis (OR = 2.48), hematoma (OR = 2.03), and pulmonary embolism (OR = 2.01) (P < 0.05 for each). These individual complications contributed to the increased odds of aggregated minor adverse events (OR = 3.68), all adverse events (OR = 3.48), and severe adverse events (OR = 2.68) (P < 0.05 for each). No statistically significant difference was observed in 5-year revision-free survival between groups. DISCUSSION This study found TSA patients with fibromyalgia to be at increased risk of adverse events within 90 days of surgery. Proper surgical planning and patient counseling are crucial to this population. Nonetheless, it was reassuring that those with fibromyalgia had similar 5-year revision-free survival compared with those without.
Collapse
Affiliation(s)
- Joshua G. Sanchez
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Albert L. Rancu
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Fortunay H. Diatta
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Anshu Jonnalagadda
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Meera M. Dhodapkar
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Leonard Knoedler
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Martin Kauke-Navarro
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Jonathan N. Grauer
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| |
Collapse
|
2
|
Kim H, Hart KD, Senders A, Schabel K, Ibrahim SA. Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups. Popul Health Manag 2024; 27:128-136. [PMID: 38442304 DOI: 10.1089/pop.2023.0310] [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] [Indexed: 03/07/2024] Open
Abstract
Hip and knee replacement have been marked by racial and ethnic disparities in both utilization and postoperative adverse events among Medicare beneficiaries, but limited knowledge exists regarding racial and ethnic differences in joint replacement care among Medicaid beneficiaries. To close this gap, this study used Medicaid claims in 2018 and described racial and ethnic differences in the utilization and postoperative adverse events of elective joint replacements among Medicaid beneficiaries. Among the 2,260,272 Medicaid beneficiaries, 5987 had an elective joint replacement in 2018. Asian (0.05%, 95% confidence interval [CI]: 0.03%-0.07%) and Hispanic beneficiaries (0.12%, 95% CI: 0.07%-0.18%) received joint replacements less frequently than American Indian and Alaska Native (0.41%, 95% CI: 0.27%-0.55%), Black (0.33%, 95% CI: 0.19%-0.48%), and White (0.37%, 95% CI: 0.25%-0.50%) beneficiaries. Black patients demonstrated the highest probability of 90-day emergency department visits (34.8%, 95% CI: 32.7%-37.0%) among all racial and ethnic groups and a higher probability of 90-day readmission (8.0%, 95% CI: 6.9%-9.0%) than Asian (3.4%, 95% CI: 0.7%-6.0%) and Hispanic patients (4.4%, 95% CI: 3.4%-5.3%). These findings indicate evident disparities in postoperative adverse events across racial and ethnic groups, with Black patients demonstrating the highest probability of 90-day emergency department visits. This study represents an initial exploration of the racial and ethnic differences in joint replacement care among Medicaid beneficiaries and lay the groundwork for further investigation into contributing factors of the observed disparities.
Collapse
Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kyle D Hart
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Angela Senders
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kathryn Schabel
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
| | - Said A Ibrahim
- Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, USA
| |
Collapse
|
3
|
Morell AT, Mildren ME, Smith S, Yoo J, Kagan R. Fibromyalgia Increases Post-Operative Healthcare Utilization Following Total Hip Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00365-0. [PMID: 37084922 DOI: 10.1016/j.arth.2023.04.019] [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: 11/15/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION Pre-operative factors can complicate the post-operative course and increase healthcare utilization following total hip arthroplasty (THA). Fibromyalgia is not generally recognized as a modifiable risk factor prior to THA. The aim of this investigation was to assess the effect of fibromyalgia on post-operative healthcare utilization following THA. METHODS Patients who underwent primary THA from 2018 to 2019 were identified from a large national database using Current Procedural Terminology (CPT) and International Classification of Diseases, tenth revision (ICD-10) codes. Patient demographics, age, sex, and pre-operative opioid use were collected. Analysis compared patients who did and did not have fibromyalgia for post-operative healthcare utilization metrics; lengths of stay (LOS), 90-day post-operative opioid usages, dislocations, and emergency room visits. Independent t-testings were used to compare LOS, and rates of ongoing opioid use. Logistic regression analyses with adjusted Odds Ratios (aORs) evaluated the risk of dislocation and emergency room visit after adjusting for demographic characteristics and comorbidities. RESULTS Compared to those who did not have fibromyalgia, patients who had fibromyalgia experienced longer LOS (P<0.0001), increased odds of opioid use 90-days post-operatively (P<0.0001), as well as increased odds of hip dislocation (P<0.0001) and presentation to the emergency room (P<0.0001). Patients who had fibromyalgia were also more likely to be "frequent flyers" with >5 emergency room visits after THA (P<0.0001). CONCLUSIONS Fibromyalgia can complicate post-operative care following THA with increased LOS, higher rates of opioid use, and increased odds of dislocation and emergency room visits. As focus shifts to pre-operative optimization and risk stratification, more attention should be placed on fibromyalgia prior to THA.
Collapse
Affiliation(s)
- Aidan T Morell
- Department of Orthopaedics and Rehabilitation Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon, 97239
| | - Mark E Mildren
- Slocum Center for Orthopedics & Sports Medicine, 55 Coburg Road, Eugene, Oregon, 97401
| | - Spencer Smith
- Department of Orthopaedics and Rehabilitation Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon, 97239
| | - Jung Yoo
- Department of Orthopaedics and Rehabilitation Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon, 97239
| | - Ryland Kagan
- Department of Orthopaedics and Rehabilitation Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon, 97239.
| |
Collapse
|
4
|
Alexander JS, Redfern RE, Duwelius PJ, Berend KR, Lombardi AV, Crawford DA. Use of a Smartphone-Based Care Platform After Primary Partial and Total Knee Arthroplasty: 1-Year Follow-Up of a Prospective Randomized Controlled Trial. J Arthroplasty 2023:S0883-5403(23)00213-9. [PMID: 36889524 DOI: 10.1016/j.arth.2023.02.082] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND The rise in demand of knee arthroplasty has led the industry to develop methods to decrease costs of care, such as novel methods of delivering physiotherapy, including smartphone-based exercise educational platforms. The purpose of this study was to determine the noninferiority of one such system after primary knee arthroplasty as compared to traditional in-person physiotherapy. METHODS A prospective, multicenter randomized clinical trial was conducted comparing standard of care rehabilitation to a smartphone-based care platform after primary knee arthroplasty from January 2019 to February 2020. One-year patient outcomes, satisfaction scores, and utilizations of health care resources were analyzed. A total of 401 patients was available for analysis-241 in the control and 160 in the treatment group. RESULTS There were 194 (94.6%) patients in the control group who required 1 or more physiotherapy visits compared to only 97 (60.6%) patients in the treatment group (P < .001). Emergency department visits within 1 year occurred in 13 (5.4%) patients and 2 (1.3%) patients in the control and treatment groups, respectively (P = .03). The change in mean Knee Injury and Osteoarthritis Outcome Score for joint replacement scores at 1 year was similar between both the groups (32.1 ± 1 6.8 versus 30.1 ± 18.1, P = .32). CONCLUSION Implementation of this smartphone/smart watch care platform showed similar outcomes to traditional care models at 1 year postoperative. Traditional physiotherapy and emergency department visits occurred at much lower rates in this cohort, which could alleviate the need for health care dollars spent by reducing postoperative costs and enhancing communication across the health care system.
Collapse
|
5
|
Ninety-Day Emergency Department Visits After Ankle Fracture Surgery. J Am Acad Orthop Surg 2023; 31:e51-e57. [PMID: 36548157 DOI: 10.5435/jaaos-d-22-00484] [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: 05/13/2022] [Accepted: 09/04/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Emergency department (ED) visits after orthopaedic procedures such as ankle fracture open reduction and internal fixation (ORIF) have received less attention than other outcomes. This study analyzed 90-day ED visits after ankle fracture surgery in a national database to better characterize the incidence, timing, risk factors, and reasons. METHODS Ankle fractures undergoing ORIF were extracted from the PearlDiver M91Ortho 2010 to 2020Q3 data set. Patients were excluded for age younger than 18 years, presence of concomitant fractures, and <90 days of database follow-up. Patient age, sex, Elixhauser Comorbidity Index score, region of the country, and insurance plan were analyzed as predictors for 90-day ED utilization using multivariate logistic regression. Incidence of readmissions and incidence, timing, risk factors, and reasons for ED visits were determined. RESULTS Of 87,662 ankle fracture ORIF patients identified, ED visits were noted within 90 days of surgery for 10,087 (11.5%) while 4,030 (4.6%) were readmitted. One ED visit was noted for 6,102 patients, two visits for 2,654, three visits for 787, and more than three visits for 544. The greatest weekly incidence of ED visits was observed in weeks 1 and 2, with 2.9% and 3.1% of the entire cohort visiting in each week respectively. Factors independently associated with 90-day ED utilization included younger age (odds ratio [OR] 1.21 per decade decrease, P < 0.001), greater Elixhauser Comorbidity Index score (OR 1.40 per two-point increase, P < 0.001), and Medicaid insurance (OR 1.92, P < 0.001). In the first two postoperative weeks, 71% of ED visits were attributed to issues directly involving the surgical site while in subsequent weeks, most visits did not involve the surgical site (65%). DISCUSSION Many patients visit the ED after ankle fracture surgery. The greatest ED utilization was during the first two postoperative weeks, and reasons for visits were defined. These findings have implications for optimizing care pathways and targeting resource allocation.
Collapse
|
6
|
Ratnasamy PP, Kammien AJ, Gouzoulis MJ, Oh I, Grauer JN. Emergency Department Visits Within 90 Days of Total Ankle Replacement. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221134255. [PMID: 36324696 PMCID: PMC9619275 DOI: 10.1177/24730114221134255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Total ankle replacement (TAR) utilization in the United States has steeply increased in recent decades. Emergency department (ED) visits following TAR impacts patient satisfaction and health care costs and warrant exploration. Methods This retrospective cohort study utilized the 2010 to 2019 M91Ortho PearlDiver data set to identify TAR patients with at least 90 days of follow-up. PearlDiver contains billing claims data across all sites of care throughout the United States for all indications for care. Patient factors extracted included age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which surgery was performed, insurance plan, and postoperative hospital length of stay. Ninety-day postoperative ED visit incidence, timing, frequency, and primary diagnoses were identified and compared to 1-year postoperative ED visit baseline data. Univariate and multivariate logistic regression analyses were used to determine risk factors for ED visits. Results Of 5930 TAR patients identified, ED visits within 90 days were noted for 497 (8.4%) patients. Of all ED visits, 32.0% occurred within 2 weeks following surgery. Multivariate analysis revealed several predictors of ED utilization: younger age (odds ratio [OR] 1.35 per decade decrease), female sex (OR 1.20), higher ECI (OR 1.32 per 2-point increase), TAR performed in the western US (OR 1.34), and Medicaid coverage (OR 2.70; 1.71-4.22 relative to Medicare) (P < .05 each). Surgical site issues comprised 78.0% of ED visits, with surgical site pain (57.0%) as the most common problem. Conclusion Of 5930 TAR patients, 8.4% returned to the ED within 90 days of surgery, with predisposing demographic factors identified. The highest incidence of ED visits was in the first 2 postoperative weeks, and surgical site pain was the most common reason. Pain management pathways following TAR should be able to be adjusted to minimize the occurrence of postoperative ED visits, thereby improving patient experiences and decreasing health care utilization/costs. Level of Evidence Level III, retrospective cohort study.
Collapse
Affiliation(s)
- Philip P. Ratnasamy
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Alexander J. Kammien
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Michael J. Gouzoulis
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Irvin Oh
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Jonathan N. Grauer
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
- Jonathan N. Grauer, MD, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06510, USA.
| |
Collapse
|
7
|
Su SF, Lin SN. Effects of comprehensive geriatric care on depressive symptoms, emergency department visits, re-hospitalization and discharge to the same residence in older persons receiving hip-fracture surgery: A meta-analysis. Int J Nurs Pract 2022; 28:e13099. [PMID: 35978458 DOI: 10.1111/ijn.13099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 06/04/2022] [Accepted: 07/23/2022] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to evaluate depressive symptoms, emergency department visits, re-hospitalization and discharge to the same residence of comprehensive geriatric care in patients receiving hip-fracture surgery. BACKGROUND Hip fractures among older persons result in restricted activities of daily living, longer hospital stays, frequent emergency department visits and re-presentation to hospital, which may increase depressive symptoms and death risk. The benefits of comprehensive geriatric care have not been determined. DESIGN A five-step Cochrane collaboration meta-analysis was used. DATA SOURCES Randomized controlled trials published from 1980 to 2020 in which comprehensive geriatric care was provided following hip-fracture surgery were retrieved from the Cochrane Library, Clinical Key, Embase, MEDLINE, OVID and PubMed databases. Indicators were depressive symptoms, emergency department visits, re-hospitalization and discharge to the same residence. REVIEW METHODS The Group Reading Assessment, Risk of Bias 2.0 tool, modified Jadad scale and Comprehensive Meta-Analysis Version 3 software were used. RESULTS Overall, 1291 patients from six randomised controlled trials were included. Comprehensive geriatric care improved depressive symptoms and lowered emergency department visits but did not improve re-hospitalization rates or discharge to the same residence. CONCLUSION Comprehensive geriatric care should include depression management and individualized care plans. Further depression-related studies are required to verify their benefits.
Collapse
Affiliation(s)
- Shu-Fen Su
- Department of Nursing, National Taichung University of Science and Technology, Taichung, Taiwan
| | - Shu-Ni Lin
- Department of Nursing, Taichung Hospital, Ministry of Health and Welfare, Taichung, Taiwan
| |
Collapse
|
8
|
Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program. J Arthroplasty 2022; 37:1241-1246. [PMID: 35227815 DOI: 10.1016/j.arth.2022.02.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Concerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution's exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A). METHODS We reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions. Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions. RESULTS Post-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224). CONCLUSIONS Since leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.
Collapse
|
9
|
Page PRJ, Field MH, Vetharajan N, Smith A, Duggleby L, Cazzola D, Whitehouse MR, Gill R. Incidence and predictive factors of problems after fixation of trochanteric hip fractures with sliding hip screw or intramedullary devices. Hip Int 2022; 32:543-549. [PMID: 32927967 DOI: 10.1177/1120700020959339] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Hip fractures are common and disabling injuries, usually managed surgically. The most common type outside the joint capsule are trochanteric fractures, usually fixed with either sliding hip screw or intramedullary nail. Data are available in the National Hip Fracture Database (NHFD) on early failure and other major complications, but late or subtler complications may escape recording. This study sought to quantify such problems after fixation performed at 3different sites and identify their predictors. METHODS Patients with a trochanteric fracture treated at 1 of 3 sites were identified from the NHFD over a 3-year period. Any with further, related episodes of care were identified, and reasons recorded, then age- and sex-matched with those with no such episodes. Data was collected on Arbeitsgemeinschaft für Osteosynthesefragen classification, tip-apex distance, American Society of Anesthesiologists (ASA) grade, Abbreviated Mental Test Score and pre-injury mobility. The cohorts were compared, and a binomial logistic regression model used to identify predictors of problems. RESULTS A total of 4010 patients were entered in the NHFD across 3 sites between January 2013 and December 2015. Of these, 1260 sustained trochanteric fractures and 57 (4.5%) subsequently experienced problems leading to re-presentation. The most common was failure of fixation, occurring in 22 patients (1.7%). The binomial logistic regression model explained 47.6% of the variance in incidence of postoperative problems with ASA grade and tip-apex distance being predictive. DISCUSSION The incidence of re-presentation with problems was around of 5%. A failure rate of less than 2% was seen, in keeping with existing data. This study has quantified the incidence of subtler postoperative problems and identified their predictors. The type of implant used was not amongst them and patients with both implants experienced problems. Fixation continues to yield imperfect results, but patient health and robust surgical technique remain important factors in a good outcome.
Collapse
Affiliation(s)
- Piers R J Page
- Frimley Park Hospital NHS Foundation Trust, Camberley, UK
| | | | | | | | | | | | - Michael R Whitehouse
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK.,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Richie Gill
- Department of Mechanical Engineering, University of Bath, Bath, UK
| |
Collapse
|
10
|
Kiskaddon EM, Soehnlen NT, Erb E, Froehle AW, Green U, Krishnamurthy A. Preoperative Emergency Department Visits Are Predictive of 90-Day Postoperative Emergency Department Visits and Discharge Disposition in Total Knee Arthroplasty Patients. J Knee Surg 2022; 35:640-644. [PMID: 32906159 DOI: 10.1055/s-0040-1716414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The increasing number of patients undergoing total knee arthroplasty (TKA) has resulted in efforts to better understand patient utilization of healthcare services in the 90-day postoperative period. The primary purpose of this study was to examine whether emergency department (ED) visits in the year prior to elective TKA were predictive of postoperative ED visits in the 90-day global period following surgery. A retrospective chart review was performed for all patients undergoing TKA from June 1, 2011 to December 31, 2015 at a Veterans Affairs hospital. Total number of ED visits in the year prior to surgery and 90 days following surgery were tabulated. Binary and ordinal logistic regression analyses were utilized to determine if preoperative ED visits were predictive of postoperative ED visits. The significance level was set to α = 0.05. Overall, 611 eligible TKA procedures were performed. The logistic regression model for postoperative ED visits was significant (p < 0.001), with the number of preoperative ED visits (1 vs. 0: p < 0.001; 2 vs. 1: p = 0.012) and presence of diabetes (p = 0.007) both predicting the likelihood of a postoperative ED visit. Healthcare changes that are redefining the concept of quality of care to include the postoperative care episode, coupled with an increasingly aging population in need of TKA, will continue to challenge orthopaedic surgeons to provide safe, competent, and cost-effective care to patients. The results of this study demonstrate that a patient's propensity to visit the ED prior to TKA is predictive of a tendency to do so postoperatively and is of use to surgeons when evaluating and counselling patients who will be undergoing a TKA.
Collapse
Affiliation(s)
- Eric M Kiskaddon
- Dayton VA Medical Center, Dayton, Ohio.,Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, Ohio
| | - Neil T Soehnlen
- Dayton VA Medical Center, Dayton, Ohio.,Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, Ohio
| | - Eric Erb
- Dayton VA Medical Center, Dayton, Ohio.,Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, Ohio
| | - Andrew W Froehle
- Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, Ohio
| | | | - Anil Krishnamurthy
- Dayton VA Medical Center, Dayton, Ohio.,Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, Ohio
| |
Collapse
|
11
|
Fixation vs Arthroplasty for Femoral Neck Fracture in Patients Aged 40-59 Years: A Propensity-Score-Matched Analysis. Arthroplast Today 2022; 14:175-182. [PMID: 35342781 PMCID: PMC8943217 DOI: 10.1016/j.artd.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/26/2021] [Accepted: 10/29/2021] [Indexed: 11/23/2022] Open
Abstract
Background Methods Results Conclusions
Collapse
|
12
|
Vakharia RM, Ehiorobo JO, Sodhi N, Mannino A, Mont MA, Roche MW. Reasons and Risk Factors for Emergency Department Visits After Primary Total Knee Arthroplasty: An Analysis of 1.3 Million Patients. J Arthroplasty 2021; 36:2313-2318.e2. [PMID: 33745799 DOI: 10.1016/j.arth.2021.02.077] [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: 12/06/2020] [Revised: 02/17/2021] [Accepted: 02/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Well-powered studies investigating the relationship of emergency department (ED) visits and total knee arthroplasty (TKA) are limited. Therefore, the specific aims of this study were to: 1) compare patient demographics of patients who did and did not have an ED visit; and for the visits, identified: 2) leading reasons; and 3) risk factors for ED visits (prearthroplasty/postarthroplasty). METHODS Patients undergoing primary TKA who had an ED visit within 90 days after their index procedure were identified from a nationwide database. The query yielded 1,364,655 patients who did (n = 5689) and did not have (n = 1,358,966) an ED visit. Baseline demographics such as age, sex, and comorbidity prevalence between the two cohorts; reasons for ED visits; and prearthroplasty and postarthroplasty risk factors were analyzed. Odds ratios (ORs) of ED visits were assessed using multivariate binomial logistic regression analyses. A P-value less than 0.001 was considered statistically significant. RESULTS Patients who did and did not have ED visits differed with respect to age (P < .0001) and mean Elixhauser Comorbidity Index scores (9 vs 6, P < .0001). Musculoskeletal etiologies were the most common reason for ED visits. Hypertension was the greatest contributor to ED visits prearthroplasty and postarthroplasty. Comorbid conditions associated with ED visits postarthroplasty included peripheral vascular disease (OR: 1.61, P < .0001), coagulopathy (OR: 1.58, P < .0001), and rheumatoid arthritis (OR: 1.56, P < .0001). CONCLUSION By identifying demographic patterns of patients, reasons, and risk factors, the information found from this study can help identify targets for quality improvement to potentially reduce the incidence of ED visits after primary TKA.
Collapse
Affiliation(s)
- Rushabh M Vakharia
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Joseph O Ehiorobo
- Department of Orthopaedic Surgery, State University of New York Downstate, Brooklyn, NY
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Northwell Health, Long Island Jewish Hospital, New York, NY
| | - Angelo Mannino
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Michael A Mont
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Martin W Roche
- Department of Orthopaedic Surgery, Hospital for Special Surgery, West Palm Beach, FL
| |
Collapse
|
13
|
Abstract
AIMS There is concern that aggressive target pricing in the new Bundled Payment for Care Improvement Advanced (BPCI-A) penalizes high-performing groups that had achieved low costs through prior experience in bundled payments. We hypothesize that this methodology incorporates unsustainable downward trends on Target Prices and will lead to groups opting out of BPCI Advanced in favour of a traditional fee for service. METHODS Using the Centers for Medicare and Medicaid Services (CMS) data, we compared the Target Price factors for hospitals and physician groups that participated in both BPCI Classic and BPCI Advanced (legacy groups), with groups that only participated in BPCI Advanced (non-legacy). With rebasing of Target Prices in 2020 and opportunity for participants to drop out, we compared retention rates of hospitals and physician groups enrolled at the onset of BPCI Advanced with current enrolment in 2020. RESULTS At its peak in July 2015, 342 acute care hospitals and physician groups participated in Lower Extremity Joint Replacement (LEJR) in BPCI Classic. At its peak in March 2019, 534 acute care hospitals and physician groups participated in LEJR in BPCI Advanced. In January 2020, only 14.5% of legacy hospitals and physician groups opted to stay in BPCI Advanced for LEJR. Analysis of Target Price factors by legacy hospitals during both programmes demonstrates that participants in BPCI Classic received larger negative adjustments on the Target Price than non-legacy hospitals. CONCLUSION BPCI Advanced provides little opportunity for a reduction in cost to offset a reduced Target Price for efficient providers, as made evident by the 85.5% withdrawal rate for BPCI Advanced. Efficient providers in BPCI Advanced are challenged by the programme's application of trend and efficiency factors that presumes their cost reduction can continue to decline at the same rate as non-efficient providers. It remains to be seen if reverting back to Medicare fee for service will support the same level of care and quality achieved in historical bundled payment programmes. Cite this article: Bone Joint J 2021;103-B(6 Supple A):119-125.
Collapse
Affiliation(s)
- Bryan D Springer
- OrthoCarolina Hip and Knee Centre, Charlotte, North Carolina, USA.,Orthopaedic Surgery, Atrium Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Jordan McInerney
- Healthcare Outcomes Performance Company (HOPCo), Phoenix, Arizona, USA
| |
Collapse
|
14
|
Gutiérrez Rodríguez C, Asmar Murgas MA, Camacho Uribe A, Barrios Diaz V, Bonilla León G, Llinás Volpe A. Postoperative morbidity and mortality in total joint arthroplasty: Exploring the limits of early discharge. J Clin Orthop Trauma 2021; 14:1-7. [PMID: 33717890 PMCID: PMC7919967 DOI: 10.1016/j.jcot.2020.10.048] [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: 08/11/2020] [Revised: 10/08/2020] [Accepted: 10/24/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION In order to enhance cost-effectiveness, shorter hospital stays have been adopted following hip or knee replacement surgery. This study seeks to describe the incidence of morbidity and mortality, five days after patients were taken to surgery with an expected hospital stay of four days. METHODS Utilizing an Institutional Joint Replacement database, a descriptive study was carried out using a retrospective cohort of 1233 procedures in 1100 patients between 2012 and 2016. These were followed up for three months to evaluate morbidity and mortality in the postoperative period. RESULTS Complications were classified as minor or major (these were defined as any adverse event that can threaten a patient's life or had the potential to result in readmission). Of the cohort, 18 (1.5%) patient procedures presented one or more major complications. On the first postoperative day 3 major complications occurred (including one death). On the second and third day, 4 major complications were registered each day. On the fourth day after surgery, there were no major complications. On the fifth day 1 major complication was identified. After patient discharge there were 6 major complications reported. DISCUSSION The balance between early discharge and out-of-hospital morbidity as well as the frequency of hospital readmission must be the basis to determine whether a patient's hospital stay should be reduced. According to our results, it seems to be safe to shorten hospital stay in young and healthy patients. Furthermore, only orthopedic teams that have minimal rates of outpatient complications and adhere to high standards of care should consider reducing hospital stay.
Collapse
Affiliation(s)
- Camilo Gutiérrez Rodríguez
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Carrera 7 No. 117 – 15, Bogotá, Colombia
| | - María Alejandra Asmar Murgas
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Carrera 7 No. 117 – 15, Bogotá, Colombia
| | - Abelardo Camacho Uribe
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Carrera 7 No. 117 – 15, Bogotá, Colombia
| | - Valeria Barrios Diaz
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Carrera 7 No. 117 – 15, Bogotá, Colombia
| | - Guillermo Bonilla León
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá. School of Medicine, Universidad de Los Andes. School of Medicine, Universidad del Rosario, Carrera 7 No. 117 – 15, Bogotá, Colombia
| | - Adolfo Llinás Volpe
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá. School of Medicine, Universidad de Los Andes. School of Medicine, Universidad del Rosario, Carrera 7 No. 117 – 15, Bogotá, Colombia
| |
Collapse
|
15
|
Maldonado-Rodriguez N, Ekhtiari S, Khan MM, Ravi B, Gandhi R, Veillette C, Leroux T. Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review. J Arthroplasty 2020; 35:3038-3045.e1. [PMID: 32540306 DOI: 10.1016/j.arth.2020.05.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Recent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty. METHODS PubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means. RESULTS Twenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits. CONCLUSION ED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.
Collapse
Affiliation(s)
- Naomi Maldonado-Rodriguez
- Division of Orthopaedic Surgery, Department of Surgery, The Arthritis Program, University Health Network, Toronto, Ontario, Canada
| | - Seper Ekhtiari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Moin M Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rajiv Gandhi
- Division of Orthopaedic Surgery, Department of Surgery, The Arthritis Program, University Health Network, Toronto, Ontario, Canada
| | - Christian Veillette
- Division of Orthopaedic Surgery, Department of Surgery, The Arthritis Program, University Health Network, Toronto, Ontario, Canada
| | - Timothy Leroux
- Division of Orthopaedic Surgery, Department of Surgery, The Arthritis Program, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
16
|
Plate JF, Ryan SP, Bergen MA, Hong CS, Mont MA, Bolognesi MP, Seyler TM. Patient Risk Profile for Unplanned 90-Day Emergency Department Visits Differs Between Total Hip and Total Knee Arthroplasty. Orthopedics 2020; 43:295-302. [PMID: 32931589 DOI: 10.3928/01477447-20200818-02] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/25/2019] [Indexed: 02/03/2023]
Abstract
Numerous studies have explored 90-day readmissions following total joint arthroplasty; however, there is a paucity of literature concerning 90-day emergency department (ED) visits. The authors aimed to characterize the risk factors for ED presentations and to determine the primary reasons for return, hypothesizing that certain medical comorbidities would account for resource utilization. The institutional database was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were stratified based on return visits to the ED within 90 days postoperatively. Univariable and multivariable analyses were performed to determine the factors most predictive of ED return for each THA and TKA. A total of 10,479 procedures resulted in 1234 90-day ED visits made by 937 patients. Significant predictors of 90-day ED return after THA included black race, age older than 80 years, congestive heart failure, valvular heart disease, metastatic disease, peripheral vascular disease, alcoholism, drug use, depression, and discharge to a skilled nursing facility. In contrast, only black race, liver insufficiency, cancer, and pulmonary hypertension were predictive of ED return following TKA. The primary risk factors for ED return differ for THA and TKA, and this is not currently reflected in the medical severity diagnosis-related group system. Specifically, black patients with multiple comorbidities are at high risk for unplanned ED visits following THA. This should be considered in patient counseling and outreach programs when attempting to mitigate the postoperative risks and to decrease 90-day resource utilization in this patient population. [Orthopedics. 2020;43(5):295-302.].
Collapse
|
17
|
Sivasundaram L, Trivedi NN, Kim CY, Du J, Liu RW, Voos JE, Salata M. Emergency Department Utilization After Elective Hip Arthroscopy. Arthroscopy 2020; 36:1575-1583.e1. [PMID: 32109576 DOI: 10.1016/j.arthro.2020.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/26/2020] [Accepted: 02/01/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE (1) To identify the most common reasons for presentation to the emergency department (ED) after hip arthroscopy and (2) to determine preoperative risk factors for these ED visits. METHODS Patients undergoing elective hip arthroscopy between the start of 2014 and the third quarter of 2015 were retrospectively evaluated using discharge records from New York and Florida. The primary outcome was all-cause 7-, 30-, and 90-day ED utilization. Reasons for presentation to the ED were recorded and manually stratified. Bivariate and multivariate analyses were performed to identify independent predictors of ED utilization. RESULTS The overall rate of postoperative ED visits after hip arthroscopy was 1.8% at 7 days, 3.5% at 30 days, and 6.6% at 90 days. Postoperative pain was the most common reason for visiting the ED at all time points (25.4%, 23.7%, and 20.3%, respectively), followed by gastrointestinal complaints (19.5%, 15.0%, and 15.3%, respectively) and neurologic complaints (8.7%, 9.8%, and 10.5%, respectively). Female sex (relative risk [RR], 1.86; 95% confidence interval [CI], 1.35-2.54; P < .001), Medicare insurance (RR, 2.39; 95% CI, 1.41-4.04; P < .001), and Medicaid insurance (RR, 3.45; 95% CI, 2.37-5.04; P < .001) were identified as independent risk factors for ED utilization at 90 days postoperatively. Of all patients who presented to the ED, only 3.9% were admitted to the hospital. CONCLUSIONS ED visits after elective hip arthroscopy are uncommon. The most common reason for a visit is postoperative pain, followed by gastrointestinal and neurologic complaints. After accounting for confounding, we found that female sex, Medicare and Medicaid insurance status, and hypertension were risk factors for all-cause ED visits at up to 90 days postoperatively. Only 4% of patients who present to the ED require inpatient hospital admission. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
Collapse
Affiliation(s)
- Lakshmanan Sivasundaram
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Nikunj N Trivedi
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Chang-Yeon Kim
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Jerry Du
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Raymond W Liu
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - James E Voos
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, U.S.A.; University Hospitals Cleveland, Sports Medicine Institute, Cleveland, Ohio, U.S.A
| | - Michael Salata
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, U.S.A.; University Hospitals Cleveland, Sports Medicine Institute, Cleveland, Ohio, U.S.A..
| |
Collapse
|
18
|
Ross TD, Dvorani E, Saskin R, Khoshbin A, Atrey A, Ward SE. Temporal Trends and Predictors of Thirty-Day Readmissions and Emergency Department Visits Following Total Knee Arthroplasty in Ontario Between 2003 and 2016. J Arthroplasty 2020; 35:364-370. [PMID: 31732370 DOI: 10.1016/j.arth.2019.09.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is the second most common surgery performed in Canada. Understanding and improving quality metrics associated with such high-volume procedures is of utmost importance to maximize value within the healthcare system, which is a balance between cost and quality. Although rates and predictors of hospital readmission and emergency department (ED) visits following TKA have previously been described in privatized healthcare settings, few studies have evaluated trends in length of stay (LOS), hospital readmissions, and ED visits following TKA in a universal single-payer system. METHODS Using data from a provincially held and validated registry, the Institute for Clinical and Evaluative Sciences, we undertook a review of all 205,152 TKAs performed in the province of Ontario, Canada, between 2003 and 2016. We determined temporal trends in utilization, LOS, readmissions, and ED visits and evaluated patient and provider predictors of hospital readmissions and ED visits using multivariate logistic regression modeling. We also grouped and described the most common reasons for readmission and ED visits based on the available International Classification of Diseases, Ninth Revision and Tenth Revision coding information. RESULTS LOS decreased significantly over the study period (P < .0001), from a median of 5 days (10th percentile 3 days, 90th percentile 8 days) in 2003 to a median of 3 days (10th percentile 2 days, 90th percentile 4 days) in 2016. All-cause 30-day readmissions did not change significantly over the study period, but the rate of ED visits increased significantly over time. Predictors of 30-day readmission following TKA included older age, male gender, lower income quartile, not having a postoperative visit with a primary care physician (PCP), increased comorbidities, longer LOS, urgent or revision surgery, admission to a teaching hospital, and discharge to an inpatient rehabilitation facility. Variables that predicted increased odds of an ED visit included older age, male gender, lower income quartile, not having a postop visit with a PCP, increasing comorbidities, year of surgery, longer LOS, and revision surgery. Admission to a teaching hospital and discharge to an inpatient rehabilitation facility showed a trend toward increased odds of an ED visit. CONCLUSIONS We identified a significant increase in ED visits following TKA in Ontario between 2003 and 2016, with no corresponding increase in hospital readmissions despite a significant temporal trend toward shorter LOS. Predictors of ED visits and readmissions were similar, including male gender, lower income, higher comorbidities, and lacking a PCP visit postoperatively. Increased rates of ED visits following TKA in Ontario represent a quality problem, as they are associated with increased cost to the public healthcare system without any substantial benefit. Interventions aimed at redirecting patients from the ED for minor postoperative concerns should be investigated, as this is likely to improve care by reducing costs, improving efficiency, and enhancing patient experience.
Collapse
Affiliation(s)
- Tayler D Ross
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Erind Dvorani
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amir Khoshbin
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Amit Atrey
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sarah E Ward
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
19
|
Thirty-day Emergency Department Utilization after Distal Radius Fracture Treatment: Identifying Predictors and Variation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2416. [PMID: 31741813 PMCID: PMC6799403 DOI: 10.1097/gox.0000000000002416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/29/2019] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Unplanned hospital visits are costly and may indicate reduced care quality. In this analysis, we aim to investigate the emergency department (ED) utilization for patients 30 days after treatment for a distal radius fracture (DRF) with an emphasis on DRF-related diagnoses of complications and examine nationwide variation in returns to the ED after treatment.
Collapse
|
20
|
Ryan SP, Plate JF, Black CS, Howell CB, Jiranek WA, Bolognesi MP, Seyler TM. Value-Based Care Has Not Resulted in Biased Patient Selection: Analysis of a Single Center's Experience in the Care for Joint Replacement Bundle. J Arthroplasty 2019; 34:1872-1875. [PMID: 31126774 DOI: 10.1016/j.arth.2019.04.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 04/05/2019] [Accepted: 04/25/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Bundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center. METHODS This is a retrospective review of primary TKA patients from July 2015 to December 2017. Patients were stratified by whether or not their surgery was performed before or after implementation of the CJR bundle. Patient demographic data including age, sex, and body mass index were collected in addition to Elixhauser comorbidities and American Society of Anesthesiologists score. In-hospital outcomes were then examined including surgery duration, length of stay, discharge disposition, and direct cost of care. RESULTS A total of 1248 TKA patients (546 Medicare and 702 commercial insurance) were evaluated, with 27.0% undergoing surgery before the start of the bundle. Compared to patients following implementation of the bundle, there was no significant difference in age, gender, or body mass index. However, pre-CJR Medicare patients were more likely to have fewer Elixhauser comorbidities (P < .001), prolonged length of stay (P < .001), and greater discharges to inpatient facilities (P = .019). There was no significant difference in direct hospital costs or operative service time comparing pre-bundle and post-bundle patients. CONCLUSION Implementation of the bundled reimbursement model did not result in biased patient selection at our institution; importantly, it also did not result in decreased hospital costs despite apparent improvement in value-based outcome metrics. This should be taken into consideration as future adaptations to reimbursement are made by the Center for Medicare and Medicaid Services.
Collapse
|
21
|
Plate JF, Ryan SP, Black CS, Howell CB, Jiranek WA, Bolognesi MP, Seyler TM. No Changes in Patient Selection and Value-Based Metrics for Total Hip Arthroplasty After Comprehensive Care for Joint Replacement Bundle Implementation at a Single Center. J Arthroplasty 2019; 34:1581-1584. [PMID: 31171397 DOI: 10.1016/j.arth.2019.05.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Alternative payment models for total hip arthroplasty (THA) were initiated by the Center for Medicare and Medicaid Services to decrease overall healthcare cost. The associated shift of financial risk to participating institutions may negatively influence patient selection to avoid high cost of care ("cherry picking," "lemon dropping"). This study evaluated the impact of the Comprehensive Care for Joint Replacement (CJR) model on patient selection, care delivery, and hospital costs at a single care center. METHODS Patients undergoing a primary THA from 2015-2017 were stratified by insurance type (Medicare and commercial insurance) and whether care was provided before (pre-CJR) or after (post-CJR) CJR bundle implementation. Patient age, gender, and body mass index, Elixhauser comorbidities and American Society of Anesthesiologists scores, were analyzed. Delivery of care variables including surgery duration, discharge disposition, length of stay, and direct hospital costs were compared pre- and post-CJR. RESULTS A total of 751 THA patients (273 Medicare and 478 commercial Insurance) were evaluated pre-CJR (29%) and post-CJR (71%). Patient demographics were similar (age, gender, BMI); however, commercially insured patients had less comorbidities pre-CJR (P = .033). Medicare patient post-CJR length of stay (P = .010) was reduced with a trend toward discharge to home (P = .019). Surgical time, operating room service time, 90-day readmissions and direct hospital costs were similar pre- and post-CJR. CONCLUSION There was no differential patient selection after CJR bundle implementation and value-based metrics (surgical time, operating room service time) were not affected. Patients were discharged sooner and more often to home. However, overall direct hospital expenses remained unchanged revealing that any cost savings were for insurance providers, not participating hospitals.
Collapse
Affiliation(s)
- Johannes F Plate
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | - Collin S Black
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | - Claire B Howell
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | - William A Jiranek
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | | | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| |
Collapse
|
22
|
Who Cares for Total Hip Arthroplasty Complications? Rates of Readmission to a Hospital Different From the Location of the Index Procedure. J Am Acad Orthop Surg 2019; 27:e669-e675. [PMID: 30379760 DOI: 10.5435/jaaos-d-18-00464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION While the number of total hip arthroplasties (THAs) performed increases, so is the number of postoperative readmissions, resulting in costly episodes of care that may disproportionately affect certain hospitals. This study examines the rates of readmission of patients to the same hospital at which they underwent index THA, compared with readmission to a different hospital. METHODS Data for all hospital discharges from 1995 to 2010 were obtained from the California Office of Statewide Health Planning and Development database. Patient outcomes, readmission data, demographic information, hospital teaching status, and location were analyzed. Regression modeling was used to evaluate the effect of hospital teaching status, location, and individual complications on the risk of readmission to the same hospital as opposed to a different hospital following the index procedure. RESULTS The overall postoperative readmission rate for specific defined complications or all-cause 30-day readmissions was 3.92%, with 75.17% readmitted to the same hospital. Following index THA at a nonacademic or academic hospital, 95.9% and 84.6% of patients were readmitted to the same type of hospital, respectively. Patients who had their index procedure at an academic hospital had lower odds for readmission to the same hospital (odds ratio, 0.734; P < 0.0001) compared with nonacademic centers. Hospitals in midsize towns had higher odds of readmission to the same hospital (odds ratio, 1.735; P = 0.0012) compared with those in large metropolitan areas. DISCUSSION Although more than 75% of patients with unplanned readmissions went to the same hospital as their index THA, academic and larger metropolitan hospitals had higher odds of postoperative readmissions to a different hospital.
Collapse
|
23
|
Kee JR, Edwards PK, Barnes CL, Foster SE, Mears SC. After-Hours Calls in a Joint Replacement Practice. J Arthroplasty 2019; 34:1303-1306. [PMID: 30956045 DOI: 10.1016/j.arth.2019.02.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/21/2019] [Accepted: 02/28/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Early discharge after joint arthroplasty requires additional resources to manage patients safely after surgery. Patient concerns must be addressed during nonbusiness hours to keep patients out of the emergency department and avoid readmissions. The goal of our study was to determine how type of system is utilized in a busy early discharge joint replacement practice. METHODS In our total joint program, we have utilized a Google phone number to give patients access to a member of the surgical team after business hours and on weekends. The duration, chief complaint, and resolution of from the phone calls were collected prospectively for 3 months (July 3, 2017-October 3, 2017). RESULTS Sixty-eight calls were received from 55 patients during the 3-month study period. Three hundred twenty-five cases were performed. The average duration of a call was 3.9 minutes. The average length of time from surgery to call was 17.5 days (range 0-442 days). Suboptimal health literacy was associated with increased calls within the first week after surgery (odds ratio = 4.1, 95% confidence interval = 1.2-14.5, P = .022). A chief complaint of pain was associated with primary versus revision surgery. (odds ratio = 3.23, 95% confidence interval = 1.08-9.86). DISCUSSION An "after-hours" telephone contact service with a member of the surgical team may help avoid unnecessary emergency department visits. About one phone call was received per day, with an average duration of 3.9 minutes per call. These additional resources are necessary to maintain patient safety and satisfaction in early discharge joint replacement.
Collapse
Affiliation(s)
- James R Kee
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Paul K Edwards
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Sara E Foster
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| |
Collapse
|
24
|
Preoperative Optimization Checklists Within the Comprehensive Care for Joint Replacement Bundle Have Not Decreased Hospital Returns for Total Knee Arthroplasty. J Arthroplasty 2019; 34:S108-S113. [PMID: 30611521 DOI: 10.1016/j.arth.2018.12.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Comprehensive Care for Joint Replacement (CJR) model has resulted in the evolution of preoperative optimization programs to decrease costs and hospital returns. At the investigating institution, one center was not within the CJR bundle and has dedicated fewer resources to this effort. The remaining centers have adopted an 11 metric checklist designed to identify and mitigate modifiable preoperative risks. We hypothesized that this checklist would improve postoperative metrics that impact costs for total knee arthroplasty (TKA) patients eligible for participation in CJR. METHODS Patients undergoing TKA from 2014 to 2018 were retrospectively reviewed. Only patients with eligible participation in CJR were included. Outcome variables including length of stay, disposition, 90-day emergency department visits, and hospital readmissions were explored. Analysis was performed to determine differences in outcomes between CJR participating and non-CJR participating hospitals within the healthcare system. RESULTS In total, 2308 TKA patients including 1564 from a CJR participating center and 744 from a non-CJR center were analyzed. There was no significant difference in patient age or gender. Patients at the non-CJR hospital had significantly higher body mass index (P < .001) and American Society of Anesthesiologists scores (P < .001), while those in the CJR network had fewer skilled nursing facility discharges (P = .028) and shorter length of stay (P < .001). However, there was no reduction in 90-day emergency department visits or readmissions. CONCLUSION The resources utilized at CJR participating hospitals, including patient optimization checklists, did not effectively alter patient outcomes following discharge. Likely, a checklist alone is insufficient for risk mitigation and detailed optimization protocols for modifiable risk factors must be investigated.
Collapse
|
25
|
Cui JJ, Gala RJ, Ondeck NT, McLynn RP, Bovonratwet P, Shultz B, Grauer JN. Incidence and considerations of 90-day readmissions following posterior lumbar fusion. Spine J 2019; 19:631-636. [PMID: 30219360 DOI: 10.1016/j.spinee.2018.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 09/08/2018] [Accepted: 09/10/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Posterior lumbar fusion (PLF) is a commonly performed procedure. The evolution of bundled payment plans is beginning to require physicians to more closely consider patient outcomes up to 90 days after an operation. Current quality metrics and other databases often consider only 30 postoperative days. The relatively new Healthcare Cost and Utilization Project Nationwide Readmissions Database (HCUP-NRD) tracks patient-linked hospital admissions data for up to one calendar year. PURPOSE To identify readmission rates within 90 days of discharge following PLF and to put this in context of 30 day readmission and baseline readmission rates. STUDY DESIGN Retrospective study of patients in the HCUP-NRD. PATIENT SAMPLE Any patient undergoing PLF performed in the first 9 months of 2013 were identified in the HCUP-NRD. OUTCOME MEASURES Readmission patterns up to a full calendar year after discharge. METHODS PLFs performed in the first 9 months of 2013 were identified in the HCUP-NRD. Patient demographics and readmissions were tracked for 90 days after discharge. To estimate the average admission rate in an untreated population, the average daily admission rate in the last quarter of the year was calculated for a subset of PLF patients who had their operation in the first quarter of the year. This study was deemed exempt by the institution's Human Investigation Committee. RESULTS Of 26,727 PLFs, 1,580 patients (5.91%) were readmitted within 30 days of discharge and 2,603 patients (9.74%) were readmitted within 90 days of discharge. Of all readmissions within 90 days, 54.56% occurred in the first 30 days. However, if only counting readmissions above the baseline admission rate of a matched population from the 4th quarter of the year (0.08% of population/day), 89.78% of 90 day readmissions occurred within the first 30 days. CONCLUSIONS The current study delineates readmission rates after PLF and puts this in the context of 30-day readmission rates and baseline readmission rates for those undergoing PLF. These results are important for patient counseling, planning, and preparing for potential bundled payments in spine surgery.
Collapse
Affiliation(s)
- Jonathan J Cui
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Raj J Gala
- Department of Orthopaedic Surgery, Emory, 49 Jesse Hill Jr Dr. SE, Atlanta, GA 30303, USA
| | - Nathaniel T Ondeck
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY 10021, USA
| | - Ryan P McLynn
- Department of Orthopaedic Surgery, University of Alabama School of Medicine, 1313 13th St South, Birmingham, AL 35205-5327, USA
| | - Patawut Bovonratwet
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Blake Shultz
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA.
| |
Collapse
|
26
|
Shibuya N, Graney C, Patel H, Jupiter DC. Predictors for Surgery-Related Emergency Department Visits within 30 Days of Foot and Ankle Surgeries. J Foot Ankle Surg 2019; 57:1101-1104. [PMID: 30197254 DOI: 10.1053/j.jfas.2018.05.003] [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: 05/09/2018] [Indexed: 02/03/2023]
Abstract
Presentation to an emergency department (ED) after foot and ankle surgeries not only causes inconvenience to patients but also increases healthcare costs. To minimize this, many major institutions have tracked these data as a part of quality improvement measures. Our previous study showed that factors associated with any (surgery-related and unrelated) postoperative ED visits were not easily modifiable by surgeons. Therefore, in the current study, we focused on factors associated specifically with surgery-related postoperative ED visits, because this may provide some insights for surgeons rather than just administrators. We examined 513 foot and ankle surgeries, of which 114 resulted in 30-day postoperative ED visits for surgery-related reasons. Demographic, medical, and surgical factors were evaluated, and risk factors were identified after adjusting for potential clinically relevant covariates. Both inpatient and outpatient surgical settings and outpatient surgical settings alone were analyzed separately. Regardless of the setting, we found that shorter surgery was protective against postoperative ED visits, as was having a previous ED visit within 6 months before surgery. In the outpatient setting, younger age and having no insurance were also proxies for a postoperative ED visit, in addition to the above factors.
Collapse
Affiliation(s)
- Naohiro Shibuya
- Professor, Texas A&M University, College of Medicine, Temple, TX; Chief, Section of Podiatry, Surgical Services, Central Texas Veterans Healthcare System, Temple, TX; Staff, Baylor Scott and White Healthcare System, Temple, TX.
| | - Colin Graney
- Podiatric Medicine and Surgery Resident, Scott and White Healthcare System, Texas A&M Health Science Center, Temple, TX
| | - Himani Patel
- Podiatric Medicine and Surgery Resident, Scott and White Healthcare System, Texas A&M Health Science Center, Temple, TX
| | - Daniel C Jupiter
- Associate Professor, Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, TX
| |
Collapse
|
27
|
Shibuya N, Patel H, Graney C, Jupiter DC. Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries. Proc AMIA Symp 2018; 31:157-160. [PMID: 29706806 DOI: 10.1080/08998280.2018.1441251] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/22/2017] [Accepted: 12/28/2017] [Indexed: 10/17/2022] Open
Abstract
The number of emergency department (ED) visits within 30 days after elective surgery has been utilized as a quality measure by many institutions. The significance of the measure as a postoperative complication in foot and ankle surgery, and risk factors for it, are unknown. We conducted a retrospective cohort study involving 386 patients to determine risk factors associated with ED visits after outpatient foot and ankle surgeries. After adjusting for clinically relevant covariates, we found that previous ED visits within 6 months of surgery, and nonelective surgeries were associated with the postoperative ED visit. Having private insurance was protective against postoperative ED visits. Though these risk factors may not be easily modifiable by surgeons, understanding them may improve patient education and transitional care to prevent overcrowding of the ED.
Collapse
Affiliation(s)
- Naohiro Shibuya
- Department of Surgery, Texas A&M University College of Medicine, Section of Podiatry, Central Texas Veterans Health Care System, and Baylor Scott and White Health Care System, Temple, Texas
| | - Himani Patel
- Department of Surgery and Podiatric Medicine, Scott and White Health Care System, Texas A&M Health Science Center, Temple, Texas
| | - Colin Graney
- Department of Surgery and Podiatric Medicine, Scott and White Health Care System, Texas A&M Health Science Center, Temple, Texas
| | - Daniel C Jupiter
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas
| |
Collapse
|
28
|
Nedza SM, Fry DE, Pine M, Reband AM, Chen P, Pine G. Peri-operative emergency department utilization in inpatient and outpatient Medicare laparoscopic cholecystectomy. Am J Surg 2018; 215:367-370. [DOI: 10.1016/j.amjsurg.2017.09.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/25/2017] [Accepted: 09/26/2017] [Indexed: 12/01/2022]
|