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Jensen TM, Pedersen JK, Waldorff FB, Søndergaard J, Overgaard S, Christensen K. Trends in Incidence of Hip Fracture and Hip Replacement in Denmark, 1996 to 2018. JAMA Netw Open 2024; 7:e249186. [PMID: 38691358 PMCID: PMC11063804 DOI: 10.1001/jamanetworkopen.2024.9186] [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: 10/23/2023] [Accepted: 03/01/2024] [Indexed: 05/03/2024] Open
Abstract
Importance The past several decades have witnessed substantial changes in treatments that are particularly relevant for older patients. Objectives To assess changes in national-level incidence rates of fracture- and musculoskeletal-related (ie, arthritis-related) hip replacement procedures for individuals aged 40 to 104 years over a 23-year period in Denmark. Design, Setting, and Participants This cohort study used national Danish health registers to include the Danish population aged 40 to 104 years from January 1, 1996, to December 31, 2018. Data were analyzed from May 31, 2022, to February 14, 2024. Main Outcomes and Measures Age- and period-specific incidence rates of hip fracture and hip replacement stratified on fracture-related vs arthritis-related indication. Results From 1996 to 2018, a total of 3 664 979 individuals were followed up for a mean (SD) of 14.6 (7.7) years, resulting in a follow-up time of 53 517 861 person-years and 158 982 (first) hip fractures, of which 42 825 involved fracture-related hip replacement procedures. A further 104 422 individuals underwent arthritis-related hip replacement. During the first 2 decades of the 21st century, hip fracture rates declined by 35% to 40% for individuals aged 70 to 104 years, and the proportion of the population undergoing fracture-related hip replacement increased by 50% to 70%, with modest variation across those aged 75 to 99 years. Rates of arthritis-related hip replacements peaked for individuals aged 75 to 79 years, but with the largest relative rate increase (75%-100%) occurring for those aged 80 to 94 years, primarily from 2001 to 2015, whereafter it remained nearly unchanged. The decline in rates of arthritis-related hip replacement after 75 to 79 years of age was gradual and did not suggest an upper age limit for access to arthritis-related hip replacement. Conclusions and Relevance The findings of this cohort study suggest that during the past several decades in Denmark, the incidence of hip fractures declined by 35% to 40% among patients aged 80 to 104 years, while the proportion receiving fracture-related hip replacement remained relatively constant after 75 years of age. During the first decades of the 21st century, arthritis-related hip replacement incidence increased by 50% to 100% among older patients and stabilized hereafter, with no apparent cutoff age for this type of procedure. These patterns indicate a positive overall trend with declining hip fracture incidence over the last decades in Denmark, and the observed hip replacement incidence suggests that age is currently not a major determining factor guiding this type of surgery.
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Affiliation(s)
- Troels Mygind Jensen
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense
- Danish Aging Research Center, Department of Public Health, University of Southern Denmark, Odense
- Research Unit for Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense
| | - Jacob Krabbe Pedersen
- Danish Aging Research Center, Department of Public Health, University of Southern Denmark, Odense
- Research Unit for Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense
| | - Frans Boch Waldorff
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense
- Danish Aging Research Center, Department of Public Health, University of Southern Denmark, Odense
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jens Søndergaard
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense
- Danish Aging Research Center, Department of Public Health, University of Southern Denmark, Odense
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kaare Christensen
- Danish Aging Research Center, Department of Public Health, University of Southern Denmark, Odense
- Research Unit for Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense
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Jabbal M, Burt J, Clarke J, Moran M, Walmsley P, Jenkins PJ. Trends in incidence and average waiting time for arthroplasty from 1998-2021: an observational study of 282,367 patients from the Scottish arthroplasty project. Ann R Coll Surg Engl 2024; 106:249-255. [PMID: 37365920 PMCID: PMC10911452 DOI: 10.1308/rcsann.2023.0039] [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] [Accepted: 04/24/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Current waiting times for arthroplasty are reported as being the worst on record. This is a combination of increasing demand, the COVID-19 pandemic and longer standing shortage of capacity. The Scottish Arthroplasty Project (SAP) is a National Audit that analyses all joint replacements undertaken in the Scottish NHS and Independent Sector. The aim of this study was to investigate the long-term trend in provision and waiting time for lower limb joint replacement surgery. METHODS All total hip replacements (THR) and total knee replacements (TKR) undertaken in NHS Scotland from 1998 to 2021 were identified. Waiting times data were analysed each year to determine the minimum, maximum, median, mean and standard deviation. RESULTS In 1998, there were 4,224 THR and 2,898 TKR with mean (range, SD) waiting time of 159.5 days (1-1,685, 119.8) and 182.9 days (1-1,946, 130.1). The minimum waiting times were both in 2013 for 7,612 THR - 78.8 days (0-539, 46) and 7,146 TKR - 79.1 days (0-489, 43.7). The maximum waiting times recorded were in 2021 with 4,070 THR waiting 283.7 days (0-945, 215) and 3,153 TKR waiting 316.8 days (4-1,064, 217). CONCLUSIONS This is the first robust large-scale national dataset showing trends in incidence and waiting time for THR and TKR over two decades. There was an expansion of activity with a reduction in waiting time, which peaked in 2013, followed by an increase in waiting time with a plateau and modest decline in the number of procedures.
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Affiliation(s)
- M Jabbal
- Royal Infirmary of Edinburgh, UK
| | - J Burt
- Golden Jubilee National Hospital, UK
| | - J Clarke
- Golden Jubilee National Hospital, UK
| | - M Moran
- Royal Infirmary of Edinburgh, UK
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Le Stum M, Gicquel T, Dardenne G, Le Goff-Pronost M, Stindel E, Clavé A. Total knee arthroplasty in France: Male-driven rise in procedures in 2009-2019 and projections for 2050. Orthop Traumatol Surg Res 2023; 109:103463. [PMID: 36374765 DOI: 10.1016/j.otsr.2022.103463] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The number of Total Knee Arthroplasty (TKA) procedures has been rising steadily for several decades in Europe and the USA. The increase varies in pace across countries, with a gradual climb in northern and central Europe, a slowing in the USA, and an exponential surge in the UK. In France, a 32.2% rise in the number of TKA and unicompartmental knee arthroplasty procedures was documented between 2012 and 2018. However, no study has focussed specifically on changes in both TKA procedures and the features of TKA patients. The objective of this study was to use the French national healthcare database to evaluate (1) increases in TKA procedures according to sex and age, (2) whether TKA is being performed at increasingly younger ages, (3) whether the comorbidity profile at TKA is changing, and (4) whether the TKA incidence rate will stabilise in the future, with a projection for 2050. HYPOTHESIS In France, the number of TKA procedures is rising in both males and females but the pace of the increases differs between sexes. MATERIAL AND METHOD This study used data collected in France in 2009-2019, separately for different age groups and for males and females, in the French national healthcare database (Système national des données de santé, SNDS) that collects information on all surgical procedures performed nationwide. Based on information about the TKA procedures, we determined (1) the TKA incidence rates with their time trends and (2) indirectly, the comorbidity profiles of the patients at TKA. Linear, Poisson, and logistic models were built to predict incidence rates in 2030, 2040, and 2050. RESULTS Between 2009 and 2019, the TKA incidence rate showed a steeper increase in males than in females (from 71.2 to 122.9 [+73%] vs. 124.2 to 181.0 [+46%], respectively). Although this increase was replicated in all age groups, it was sharper in patients younger than 65 years, in both males and females (from 20.9 to 37.9 [+82%] and 33.6 to 51.3 [+53%], respectively). During the study period, the number and proportion of patients increased in the group with mild comorbidities (from 40 093 to 67 430 TKAs, i.e., from 53.1% to 65.7% of all TKAs) but not in the other comorbidity groups. All projection models were validated. Nonetheless, the most likely scenario, provided by the logistic model, is a 33% rise by 2050 in both males and females (i.e., to 151 575 TKA procedures) with a plateau starting around 2030. CONCLUSION Although the increase in TKA procedures is more marked in males than in females, the trends are similar in both sexes, with a sharper rise in the group younger than 65 years and a shift toward patients with milder comorbidities. In the longer term, incidence rate trends follow logistic dynamics, with a plateau starting around 2030. To meet the increasing demand, a corresponding development in relevant healthcare resources must be planned. LEVEL OF EVIDENCE IV, descriptive epidemiological study.
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Affiliation(s)
- Mathieu Le Stum
- Institut national de la santé et de la recherche médicale (Inserm), laboratoire de traitement de l'information médicale (LATIM), UMR1101, 22, avenue Camille-Desmoulins, 29200 Brest, France.
| | - Thomas Gicquel
- Clinique mutualiste de la porte de l'Orient, 3, rue Robert-de-la-Croix, 56324 Lorient, France
| | - Guillaume Dardenne
- Centre hospitalo-universitaire de Brest, CHRU de Brest, LATIM, UMR 1101, 2, avenue Foch, 29200 Brest, France
| | - Myriam Le Goff-Pronost
- Institut Mines-Telecom, IMT Atlantique, LATIM - Inserm UMR 1101, M@rsouin, 655, avenue du Technopôle, 29280 Plouzane, France
| | - Eric Stindel
- Centre hospitalo-universitaire de Brest, CHRU de Brest, LATIM, UMR 1101, 2, avenue Foch, 29200 Brest, France; Université de Bretagne Occidentale, UBO, LATIM, UMR 1101, 22, avenue Camille-Desmoulins, 29200 Brest, France
| | - Arnaud Clavé
- Université de Bretagne Occidentale, UBO, LATIM, UMR 1101, 22, avenue Camille-Desmoulins, 29200 Brest, France; Service d'orthopédie, clinique Saint-George, 2, avenue de Rimiez, 06100 Nice, France
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Patel I, Nham F, Zalikha AK, El-Othmani MM. Epidemiology of total hip arthroplasty: demographics, comorbidities and outcomes. ARTHROPLASTY (LONDON, ENGLAND) 2023; 5:2. [PMID: 36593482 PMCID: PMC9808997 DOI: 10.1186/s42836-022-00156-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/22/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Primary THA (THA) is a successful procedure for end-stage hip osteoarthritis. In the setting of a failed THA, revision total hip arthroplasty (rTHA) acts as a salvage procedure. This procedure has increased risks, including sepsis, infection, prolonged surgery time, blood loss, and increased length of stay. Increasing focus on understanding of demographics, comorbidities, and inpatient outcomes can lead to better perioperative optimization and post-operative outcomes. This epidemiological registry study aimed to compare the demographics, comorbidity profiles, and outcomes of patients undergoing THA and rTHA. METHODS A retrospective review of discharge data reported from 2006 to the third quarter of 2015 using the National Inpatient Sample registry was performed. The study included adult patients aged 40 and older who underwent either THA or rTHA. A total of 2,838,742 THA patients and 400,974 rTHA patients were identified. RESULTS The primary reimbursement for both THA and rTHA was dispensed by Medicare at 53.51% and 65.36% of cases respectively. Complications arose in 27.32% of THA and 39.46% of rTHA cases. Postoperative anemia was the most common complication in groups (25.20% and 35.69%). Common comorbidities in both groups were hypertension and chronic pulmonary disease. rTHA indications included dislocation/instability (21.85%) followed by mechanical loosening (19.74%), other mechanical complications (17.38%), and infection (15.10%). CONCLUSION Our data demonstrated a 69.50% increase in patients receiving THA and a 28.50% increase in rTHA from the years 2006 to 2014. The data demonstrated 27.32% and 39.46% complication rate with THA and rTHA, with postoperative anemia as the most common cause. Common comorbidities were hypertension and chronic pulmonary disease. Future analyses into preoperative optimizations, such as prior consultation with medical specialists or improved primary hip protocol, should be considered to prevent/reduce postoperative complications amongst a progressive expansion in patients receiving both THA and rTHA.
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Affiliation(s)
- Ishan Patel
- grid.413184.b0000 0001 0088 6903DMC Orthopaedics & Sports Medicine, 3990 John R Street, Detroit, MI 48201 USA
| | - Fong Nham
- grid.413184.b0000 0001 0088 6903DMC Orthopaedics & Sports Medicine, 3990 John R Street, Detroit, MI 48201 USA
| | - Abdul K. Zalikha
- grid.413184.b0000 0001 0088 6903DMC Orthopaedics & Sports Medicine, 3990 John R Street, Detroit, MI 48201 USA
| | - Mouhanad M. El-Othmani
- grid.239585.00000 0001 2285 2675Department of Orthopaedic Surgery, Columbia University Medical Center, 622 W 168th Street, New York, NY 10032 USA
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Edelmann L, Hempel M, Podsiadlo N, Schweizer N, Tong C, Galvain T, Taylor H, Schüler M. Reduced Length of Stay Following Patient Pathway Optimization for Primary Hip and Knee Arthroplasty at a Swiss Hospital. CLINICOECONOMICS AND OUTCOMES RESEARCH 2022. [DOI: 10.2147/ceor.s348475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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McConaghy KM, Orr MN, Grits D, Emara AK, Molloy RM, Piuzzi NS. What Is the 30-Day Mortality Burden After Elective Total Hip Arthroplasty? An Analysis of 194,062 Patients. J Arthroplasty 2021; 36:3513-3518.e2. [PMID: 34116914 DOI: 10.1016/j.arth.2021.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/06/2021] [Accepted: 05/14/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aims to answer the following questions regarding elective total hip arthroplasty (THA): What is (1) the overall 30-day mortality rate; (2) the mortality rate when stratified by age, comorbidities, and preoperative diagnosis; and (3) the distribution of patient demographics, comorbidities, and preoperative diagnoses between the mortality and mortality-free cohorts? METHODS The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all patients undergoing elective primary THA (2011-2018). A total of 194,062 patients were categorized based on the incidence of 30-day mortality (mortality: n = 206 vs mortality-free: n = 193,856). Patient demographics, comorbidities, and preoperative diagnosis (osteoarthritis [OA] vs non-OA) were recorded. Age category, American Society of Anesthesiologists (ASA) score, and modified Charlson Comorbidity Index (CCI) scores were normalized per 1000 and stratified by preoperative diagnosis. RESULTS The 30-day mortality rate was 0.11%. The percentage of deaths per age group (normalized per 1000) was 0% (18-29 years), 0% (30-39 years), 0.049% (40-49 years), 0.052%(50-59 years), 0.071% (60-69 years), 0.133% (70-79 years), and 0.352% (80-89 years). The percentage of deaths per ASA score was 0% (ASA I), 0.035% (ASA II), 0.174% (ASA III), and 1.008% (ASA IV). The percentage of deaths per CCI score was 0.09% (CCI = 0), 0.23% (CCI = 1), 0.74% (CCI = 2), 3.21% (CCI = 3), 4.76% (CCI = 4), and 0.57% (CCI ≥ 5). Non-OA diagnoses were significantly more frequent in the mortality cohort (16.0% vs 7.6%; P < .001). CONCLUSION The risk of mortality was highest in patients aged 80-89, patients of ASA class IV, patients with a CCI score of 4, and patients with a non-OA diagnosis. The overall rate of death was higher in the non-OA cohort compared to the OA cohort. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kara M McConaghy
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Melissa N Orr
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Daniel Grits
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
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Racial and socioeconomic disparities among patients undergoing hip arthroplasty: a New York State population analysis. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Scardino M, Di Matteo B, Martorelli F, Tanzi D, Kon E, D’Amato T. Improved patient blood management and cost saving in hip replacement surgery through the implementation of pre-operative Sucrosomial® iron supplementation: a quality improvement assessment study. INTERNATIONAL ORTHOPAEDICS 2018; 43:39-46. [DOI: 10.1007/s00264-018-4149-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/06/2018] [Indexed: 11/24/2022]
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Oh C, Slover JD, Bosco JA, Iorio R, Gold HT. Time Trends in Characteristics of Patients Undergoing Primary Total Hip and Knee Arthroplasty in California, 2007-2010. J Arthroplasty 2018; 33:2376-2380. [PMID: 29605148 DOI: 10.1016/j.arth.2018.02.079] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND As the number of total hip and knee arthroplasty cases increases, it is important to understand the burden of factors that impact patient outcomes of these procedures. This article examined the time trends in key demographics, clinical characteristics, comorbidity burden (Deyo-Charlson Comorbidity Index [CCI]), and presence of depression in patients undergoing primary total hip arthroplasty and total knee arthroplasty using population-based, all-payer inpatient database, California Healthcare Cost and Utilization Project, from 2007 to 2010. METHODS Chi-square tests and analysis of variance were used. Multivariate logistic regression analyses were also performed to compare the prevalence of depression in 2007 to later years. RESULTS In the primary total hip arthroplasty cohort, the prevalence of depression significantly increased by 20%, mean age decreased by 0.4 years, mean length of stay (LOS) decreased by 0.5 days, and having a CCI score of ≥3 increased by 30% (P value < .001 for all) over the study period. Similarly, in the primary total knee arthroplasty cohort, the prevalence of depression increased by 23%, the mean age decreased by 0.4 years, mean LOS decreased by 0.4 days, and the prevalence of CCI score of ≥3 increased by 35% (P value < .001 for all). CONCLUSION Despite the younger age of the joint arthroplasty population over time, we found increased prevalence of depression and comorbidity scores but shorter LOS. Further study is needed to determine the impact of the changing demographics of the total joint population and the best strategies to optimize their outcome with these procedures.
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Affiliation(s)
- Cheongeun Oh
- Department of Population Health, NYU School of Medicine, New York, New York
| | - James D Slover
- Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
| | - Heather T Gold
- Department of Population Health, NYU School of Medicine, New York, New York; Department of Orthopaedic Surgery, NYU School of Medicine, New York, New York
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Liu Q, Geng P, Shi L, Wang Q, Wang P. Tranexamic acid versus aminocaproic acid for blood management after total knee and total hip arthroplasty: A systematic review and meta-analysis. Int J Surg 2018; 54:105-112. [PMID: 29723672 DOI: 10.1016/j.ijsu.2018.04.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 04/03/2018] [Accepted: 04/25/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of tranexamic acid and aminocaproic acid for reducing blood loss and transfusion requirements after total knee and total hip arthroplasty. METHODS We conduct electronic searches of Medline (1966-2017.11), PubMed (1966-2017.11), Embase (1980-2017.11), ScienceDirect (1985-2017.11) and the Cochrane Library (1900-2017.11). The primary outcomes, including total blood loss, hemoglobin decline and transfusion requirements. Secondary outcomes include length of hospital stay and postoperative complications such as the incidence of deep vein thrombosis and pulmonary embolism. Each outcome is combined and calculated using the statistical software STATA 12.0. Fixed/random effect model is adopted based on the heterogeneity tested by I2 statistic. RESULTS A total of 1714 patients are analyzed across three randomized controlled trials (RCTs) and one non-RCT. The present meta-analysis reveals that TXA is associated with a significantly reduction of total blood loss and postoperative hemoglobin drop compared with EACA. No significant differences are identified in terms of transfusion rates, length of hospital stay, and the incidence of postoperative complications. CONCLUSION Although total blood loss and postoperative hemoglobin drop are significant greater in EACA groups, there is no significant difference between TXA and EACA groups in terms of transfusion rates. Based on the current evidence available, higher quality RCTs are still required for further research.
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Affiliation(s)
- Qiuliang Liu
- Department of Pediatric Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China.
| | - Peishuo Geng
- Department of Pediatric Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Longyan Shi
- Department of Pediatric Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Qi Wang
- Department of Pediatric Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Pengliang Wang
- Department of Pediatric Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
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Burn E, Edwards CJ, Murray DW, Silman A, Cooper C, Arden NK, Pinedo-Villanueva R, Prieto-Alhambra D. Trends and determinants of length of stay and hospital reimbursement following knee and hip replacement: evidence from linked primary care and NHS hospital records from 1997 to 2014. BMJ Open 2018; 8:e019146. [PMID: 29374669 PMCID: PMC5829869 DOI: 10.1136/bmjopen-2017-019146] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To measure changes in length of stay following total knee and hip replacement (TKR and THR) between 1997 and 2014 and estimate the impact on hospital reimbursement, all else being equal. Further, to assess the degree to which observed trends can be explained by improved efficiency or changes in patient profiles. DESIGN Cross-sectional study using routinely collected data. SETTING National Health Service primary care records from 1995 to 2014 in the Clinical Practice Research Datalink were linked to hospital inpatient data from 1997 to 2014 in Hospital Episode Statistics Admitted Patient Care. PARTICIPANTS Study participants had a diagnosis of osteoarthritis or rheumatoid arthritis. INTERVENTIONS Primary TKR, primary THR, revision TKR and revision THR. PRIMARY OUTCOME MEASURES Length of stay and hospital reimbursement. RESULTS 10 260 primary TKR, 10 961 primary THR, 505 revision TKR and 633 revision THR were included. Expected length of stay fell from 16.0 days (95% CI 14.9 to 17.2) in 1997 to 5.4 (5.2 to 5.6) in 2014 for primary TKR and from 14.4 (13.7 to 15.0) to 5.6 (5.4 to 5.8) for primary THR, leading to savings of £1537 and £1412, respectively. Length of stay fell from 29.8 (17.5 to 50.5) to 11.0 (8.3 to 14.6) for revision TKR and from 18.3 (11.6 to 28.9) to 12.5 (9.3 to 16.8) for revision THR, but no significant reduction in reimbursement was estimated. The estimated effect of year of surgery remained similar when patient characteristics were included. CONCLUSIONS Length of stay for joint replacement fell substantially from 1997 to 2014. These reductions have translated into substantial savings. While patient characteristics affect length of stay and reimbursement, patient profiles have remained broadly stable over time. The observed reductions appear to be mostly explained by improved efficiency.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthritis, Rheumatoid/economics
- Arthritis, Rheumatoid/surgery
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Knee/economics
- Cross-Sectional Studies
- England
- Female
- Hip Joint/pathology
- Hip Joint/surgery
- Hospital Costs/trends
- Hospital Records
- Hospitals
- Humans
- Insurance, Health, Reimbursement/trends
- Knee Joint/pathology
- Knee Joint/surgery
- Length of Stay/economics
- Length of Stay/trends
- Male
- Middle Aged
- Osteoarthritis/economics
- Osteoarthritis/surgery
- Osteoarthritis, Hip/economics
- Osteoarthritis, Hip/surgery
- Osteoarthritis, Knee/economics
- Osteoarthritis, Knee/surgery
- Primary Health Care
- State Medicine
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Affiliation(s)
- Edward Burn
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Christopher J Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alan Silman
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cyrus Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiology Unit, Southampton University, Southampton, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiology Unit, Southampton University, Southampton, UK
| | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiology Unit, Southampton University, Southampton, UK
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- GREMPAL Research Group, Idiap Jordi Gol and CIBERFes, Universitat Autonoma de Barcelona and Instituto de Salud Carlos III, Barcelona, Spain
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Effect of Type 2 Diabetes on In-Hospital Postoperative Complications and Mortality After Primary Total Hip and Knee Arthroplasty. J Arthroplasty 2017; 32:3729-3734.e2. [PMID: 28735804 DOI: 10.1016/j.arth.2017.06.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/02/2017] [Accepted: 06/24/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We aimed to compare in-hospital postoperative complications (IHPC) and in-hospital mortality between patients with and without type 2 diabetes mellitus (T2DM) undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS We analyzed data from the Spanish National Hospital Discharge Database, 2010-2014. We selected patients who had undergone THA (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 81.51) and TKA (code 81.54). Diabetic patients with THA and TKA were matched by year, age, sex, and the comorbidities included in the modified Elixhauser Comorbidity Index with a nondiabetic patient. RESULTS We identified 115,234 THA patients and 195,355 TKA patients, 12.4% and 15.6% with T2DM, respectively. We matched 10,777 and 26,640 pairs of diabetic and nondiabetic patients. In T2DM patients who had undergone THA, the incidence of urinary tract infection was higher than in nondiabetic patients (1.50% vs 1.09%, P = .007), as was that of "any IHPC" (9.68% vs 8.98%, P = .038). In patients who had undergone TKA, the incidence of postoperative anemia was significantly higher in diabetic patients (4.90% vs 4.53, P = .040), as was that of urinary tract infection (0.80% vs 0.53%, P = .025) and "any IHPC" (7.30% vs 6.76%, P = .014). In both procedures, mean length of hospital stay was significantly higher in diabetic patients; for TKA, in-hospital mortality was higher in diabetic patients (0.09% vs 0.02%, P = .002). Previous comorbidities, age, and obesity predict a higher incidence of IHPC among diabetic patients. CONCLUSIONS This study confirms the higher risk of IHPC among T2DM patients after joint arthroplasty. IHPC may result in a higher risk of mortality in patients undergoing TKA.
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Sikora-Klak J, Gupta A, Bergum C, Zarling B, Markel DC. The Evaluation of Comorbidities Relative to Length of Stay for Total Joint Arthroplasty Patients. J Arthroplasty 2017; 32:1085-1088. [PMID: 28012724 DOI: 10.1016/j.arth.2016.10.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 10/01/2016] [Accepted: 10/25/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The ability to identify those at risk for longer inpatient stay helps providers with postoperative planning and patient expectations. Decreasing length of stay (LOS) in the future will be determined by appropriate patient selection, risk stratification, and preoperative patient optimization. The purpose of this study was to identify factors that place patients at risk for extended postoperative LOSs. METHODS The study cohort included 2009 primary total knee arthroplasty (TKA) patients and 905 total hip arthroplasty (THA) patients. Patient comorbidities were prospectively identified and the LOS for each patient was tracked after a primary arthroplasty. Statistical analysis was performed to correlate which comorbidities were associated with longer inpatient stays. RESULTS In the TKA population, gender, smoking status, venous thromboembolism history, body mass index, and diabetes status were not found to be a significant predictor for the LOS. Age was found to be a factor in univariate regression testing (P < .001). In the THA population, univariate testing showed female gender (P < .001), smoking status (P = .002), and age (P < .001) to be factors, but like the TKA population, venous thromboembolism history or diabetes status was not significant. In THA multivariate analysis, age (P < .001) and female gender (P = .018) continued to be factors, but smoking was determined to be a confounding variable. CONCLUSION Age and gender were associated with a longer LOS after THA, whereas only age was a significant factor after TKA. Development of age-adjusted LOS models may help aid patient expectations and risk management.
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Affiliation(s)
- Jakub Sikora-Klak
- Department of Orthopaedic Research, Providence-Providence Park Hospital, Southfield, Michigan; The CORE Institute, Department of Orthopaedics, Southfield, Michigan
| | - Andrew Gupta
- Department of Orthopaedic Research, Providence-Providence Park Hospital, Southfield, Michigan; The CORE Institute, Department of Orthopaedics, Southfield, Michigan
| | - Christopher Bergum
- Department of Orthopaedic Research, Providence-Providence Park Hospital, Southfield, Michigan; The CORE Institute, Department of Orthopaedics, Southfield, Michigan
| | - Bradley Zarling
- Department of Orthopaedic Research, Providence-Providence Park Hospital, Southfield, Michigan; The CORE Institute, Department of Orthopaedics, Southfield, Michigan
| | - David C Markel
- Department of Orthopaedic Research, Providence-Providence Park Hospital, Southfield, Michigan; The CORE Institute, Department of Orthopaedics, Southfield, Michigan
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Olthof M, Stevens M, Zijlstra WP, Bulstra SK, van den Akker-Scheek I. Medication Use is a Better Predictor of Length of Hospital Stay in Total Hip Arthroplasty Than the American Society of Anesthetists (ASA) Score. J Arthroplasty 2017; 32:24-27. [PMID: 27444851 DOI: 10.1016/j.arth.2016.06.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 06/06/2016] [Accepted: 06/11/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Length of hospital stay (LOS) greatly influences costs of total hip arthroplasty (THA). LOS is, among others, dependent on patient comorbidity. American Society of Anesthetists (ASA) scores are traditionally used as comorbidity measure, but simple medication-based measures may suffice. Therefore, the objective of the study is to determine if medication-based measures (count of medication and the medication-based index Chronic Disease Score [CDS]) have a surplus value compared to a diagnosis-based measure for comorbidity (ASA score) to predict LOS in THA. METHODS A retrospective cohort study. THA patients from 3 hospitals were included for 2009-2013, and demographic data, comorbidity (ASA score), and medication use (count of medication and CDS) were collected. A binomial regression model was used to compare the predictive ability of the medication-based and diagnosis-based measures. RESULTS A total of 2,282 THA patients were included. Number of medications proved a statistical significant predictor of LOS. LOS increased 6% (incidence rate ratios: 10.06 [confidence interval: 1.03-1.09]) with each medication. Neither the CDS nor the ASA score had a statistically significant relation to LOS. CONCLUSION The medication-based measure count of medication is a better predictor for LOS in THA than the CDS and ASA score. This simple measure also appears to have more clinical relevance, as it has a higher range in scores than diagnosis-based indexes and is easily applicable.
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Affiliation(s)
- Marijke Olthof
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Martin Stevens
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Wierd P Zijlstra
- Department of Orthopedics, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Galenkamp H, Deeg DJH, de Jongh RT, Kardaun JWPF, Huisman M. Trend study on the association between hospital admissions and the health of Dutch older adults (1995-2009). BMJ Open 2016; 6:e011967. [PMID: 27531734 PMCID: PMC5013367 DOI: 10.1136/bmjopen-2016-011967] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/14/2016] [Accepted: 07/22/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES An increase in hospital admission rates in older people may reflect improved access to healthcare, but also declining health trends in the older population. Owing to a lack of individual-level data, the latter possibility has received little attention. The current study examines associations between health status and hospitalisation rates of older adults in the Netherlands. DESIGN Observational individual-level data linked to hospital register data. SETTING Data from 1995 to 2009 from the nationally representative Longitudinal Aging Study Amsterdam were linked to the Dutch Hospital Discharge Register. PARTICIPANTS A total of 5681 observations of 2520 respondents across 4 measurement points (each with a follow-up of 36 months; ages 65-88 years). OUTCOME MEASURES The contribution of health, demographic, psychosocial and lifestyle characteristics to time trends in hospitalisation was assessed in multivariate models. RESULTS Between 1995 and 2009, the percentage with 1 or more overnight admissions (planned or acute) increased slightly from 38.1% to 39.7%. This was due to an increase in acute admission only (22.2-27.0%). Increased prevalences of chronic diseases, functional limitations and polypharmacy accounted for part of the observed increase in acute admissions. In addition, a more than doubled prevalence of day admissions over time was observed (12.3-28.3%), a trend that was unrelated to changes in individual characteristics. CONCLUSIONS This trend study showed a contribution of declines in population health to increases in acute hospital admissions. Since these declines did not provide a full explanation, healthcare reforms and increases in treatment possibilities in this period are likely to have contributed as well.
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Affiliation(s)
- Henrike Galenkamp
- Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Dorly J H Deeg
- Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
| | - Renate T de Jongh
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Jan W P F Kardaun
- Statistics Netherlands, The Hague, The Netherlands
- Department of Public Health, Academic Medical Center, Amsterdam, The Netherlands
| | - Martijn Huisman
- Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Department of Sociology, VU University, Amsterdam, The Netherlands
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de Miguel-Diez J, Jiménez-García R, Hernández-Barrera V, Carrasco-Garrido P, Puente-Maestu L, Ramírez García L, Lopez de Andres A. Is COPD a Risk Factor for Hip Fracture? COPD 2016; 13:779-789. [PMID: 27379970 DOI: 10.1080/15412555.2016.1195348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Javier de Miguel-Diez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Rodrigo Jiménez-García
- Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Valentin Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Pilar Carrasco-Garrido
- Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Luis Puente-Maestu
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Laura Ramírez García
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Ana Lopez de Andres
- Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
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Singh JA, Schleck C, Harmsen S, Lewallen D. Clinically important improvement thresholds for Harris Hip Score and its ability to predict revision risk after primary total hip arthroplasty. BMC Musculoskelet Disord 2016; 17:256. [PMID: 27286675 PMCID: PMC4901425 DOI: 10.1186/s12891-016-1106-8] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/28/2016] [Indexed: 12/19/2022] Open
Abstract
Background Some aspects of validity are missing for the Harris Hip Score (HHS). Our objective was to examine the clinically meaningful change thresholds, responsiveness and the predictive ability of the HHS questionnaire. Methods We included a cohort of patients who underwent primary total hip arthroplasty (THA) and responded to the HHS preoperatively and at 2- or 5-year post-THA (change score) to examine the clinically meaningful change thresholds (Minimal clinically important improvement, MCII; and moderate improvement), responsiveness (effect size (ES) and standardized response mean (SRM)) based on pre- to post-operative change and the predictive ability of change score or absolute postoperative score at 2- and 5-years post-THA for future revision. Results Two thousand six hundred sixty-seven patients with a mean age of 64 years completed baseline HHS; 1036 completed both baseline and 2-year HHS and 669 both baseline and 5-year HHS. MCII and moderate improvement thresholds ranged 15.9–18 points and 39.6–40.1 points, respectively. ES was 3.12 and 3.02 at 2- and 5-years; respective SRM was 2.73 and 2.52. There were 3195 hips with HHS scores at 2-years and 2699 hips with HHS scores at 5-years (regardless of the completion of baseline HHS; absolute postoperative scores). Compared to patients with absolute HHS scores of 81–100 (score range, 0–100), patients with scores <55 at 2- and 5-years had higher hazards (95 % confidence interval) of subsequent revision, 4.34 (2.14, 7.95; p < 0.001) and 3.08 (1.45, 5.84; p = 0.002), respectively. Compared to HHS score improvement of >50 points from preoperative to 2-years post-THA, lack of improvement/worsening or 1–20 point improvement were associated with increased hazards of revision, 18.10 (1.41, 234.83; p = 0.02); and 6.21 (0.81, 60.73; p = 0.10), respectively. Conclusions HHS is a valid measure of THA outcomes and is responsive to change. Both absolute HHS postoperative scores and HHS score change postoperatively are predictive of revision risk post-primary THA. We defined MCID and moderate improvement thresholds for HHS in this study.
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Affiliation(s)
- Jasvinder A Singh
- Department of Medicine, Medicine Service, Birmingham VA Medical Center, University of Alabama, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294, USA. .,Departments of Orthopedic Surgery, Mayo Clinic School of Medicine, Rochester, MN, USA. .,Center for Surgical Medical Acute care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, AL, USA. .,Division of Epidemiology, School of Public Health, University of Alabama, Birmingham, AL, USA.
| | - Cathy Schleck
- Departments of Biostatistics, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Scott Harmsen
- Departments of Biostatistics, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - David Lewallen
- Center for Surgical Medical Acute care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, AL, USA
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Weiss RJ, Garellick G, Kärrholm J, Hailer NP. Total Hip Arthroplasty in 6690 Patients with Inflammatory Arthritis: Effect of Medical Comorbidities and Age on Early Mortality. J Rheumatol 2016; 43:1320-7. [DOI: 10.3899/jrheum.151287] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2016] [Indexed: 12/21/2022]
Abstract
Objective.We analyzed early mortality after total hip arthroplasty (THA) in patients with inflammatory arthritis (IA), adjusting for medical comorbidities and socioeconomic background.Methods.Data on 6690 patients with IA who underwent THA during 1992–2012 were extracted from the Swedish Hip Arthroplasty Register. Data on comorbidity, measured using the Charlson Comorbidity Index (CCI), and socioeconomic data were gathered from the Swedish National Inpatient Register and Statistics Sweden. The CCI was divided into low (0), moderate (1–2), and high (> 2). Cox proportional hazards models were fitted to calculate adjusted HR of early mortality, with 95% CI.Results.Twenty-five patients (0.4%) died within 0–90 days, giving a 90-day unadjusted survival rate of 99.6% (CI 99.5–99.8). Comorbidity was associated with an increased risk of death within 90 days postoperatively [high vs low CCI: adjusted HR 9.0 (CI 1.6–49.9)]. There was a trend toward lower risk of death during the period 1999–2005, although patients operated on during this period had more comorbidities than those operated on from 1992 to 1998. A large proportion of patients was re-admitted to hospital within 90 days after the index procedure (30.2%), but rarely for cardiovascular reasons.Conclusion.Medical comorbidity and an age above 75 years are associated with a substantial increase in the risk of early death after THA in patients with IA. Awareness of potential risk factors may alert clinicians and thus improve perioperative care.
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Capón-García D, López-Pardo A, Alves-Pérez M. Causes for revision surgery in total hip replacement. A retrospective epidemiological analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2016. [DOI: 10.1016/j.recote.2016.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Capón-García D, López-Pardo A, Alves-Pérez MT. Causes for revision surgery in total hip replacement. A retrospective epidemiological analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2016; 60:160-6. [PMID: 26944512 DOI: 10.1016/j.recot.2016.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/10/2016] [Accepted: 01/20/2016] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To determine the impact of each cause of revision surgery in total hip arthroplasty during the period 2009-2013. To analyse the relationship between these causes with different variables. MATERIALS AND METHODS A study was conducted on 127 patients who had hip replacement revision surgery in our hospital during this period. Parameters, such as age, sex, date of primary arthroplasty, prosthetic replacement date, and main cause of the revision were recorded. Those revisions performed within 5 years after the primary arthroplasty were considered as early rescue. RESULTS The most common cause of rescue was aseptic loosening in 38 (30%) followed by instability in 30 (24%). In terms of age at the time of rescue, statistically significant differences were found, with it being significantly higher in patients re-operated for a fracture. Differences in age at first surgery were found to be 7 years younger than those with late rescue (63.40) with respect to early (70.21). DISCUSSION Similar results to ours have been observed in other published series, except for the higher incidence of instability in early rescue. CONCLUSIONS This study demonstrates aseptic loosening and instability as the most frequent causes of revision surgery in our hospital. Age is a very influential factor in relation to longevity of primary arthroplasty. Complications were higher in when the primary hip replacement is implanted in older patients.
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Affiliation(s)
- D Capón-García
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Lucus Augusti, Lugo, España.
| | - A López-Pardo
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Lucus Augusti, Lugo, España
| | - M T Alves-Pérez
- Grupo NECOM-Neurocomunicación y Marketing, Universidade de Vigo, Vigo, España
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Singh JA, Schleck C, Harmsen WS, Jacob AK, Warner DO, Lewallen DG. Current tobacco use is associated with higher rates of implant revision and deep infection after total hip or knee arthroplasty: a prospective cohort study. BMC Med 2015; 13:283. [PMID: 26586019 PMCID: PMC4653911 DOI: 10.1186/s12916-015-0523-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 11/05/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Tobacco smoking is a risk factor for several adverse post-operative outcomes. We aimed to compare the rates of complications in current tobacco users and non-users who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS All patients who underwent primary THA or TKA at the Mayo Clinic from 2010-2013 were included in the study. Current tobacco use was defined as the use of cigarettes, cigars, pipes, or smokeless tobacco reported at the time of index THA or TKA; current non-users were former users or never users. We used Cox proportional hazards regression to assess the association of current tobacco use status with each post-THA/TKA complication, using hazard ratios and 95% confidence intervals (CI). RESULTS Tobacco use status was available for 7926 patients (95%) and not available for 446 patients (5%); 565 (7%) were current tobacco users. Compared to non-users, current tobacco users were more likely to be male (p < 0.001), and less likely to be obese (p ≤ 0.008), be older than 60 years, have Charlson score >0 or have undergone TKA rather than THA (p < 0.001 each). The hazard ratios for deep infection (2.37; 95% CI 1.19, 4.72; p = 0.01) and implant revision (1.78; 95% CI 1.01, 3.13; p = 0.04) were higher in current tobacco users than in non-users. No significant differences were noted for periprosthetic fractures or superficial infections. CONCLUSIONS We noted that current tobacco use was associated with high risk of deep infection and implant revision after primary THA or TKA. Future studies should determine the optimal time for tobacco use cessation before elective surgeries such as THA and TKA to improve short-term and long-term arthroplasty outcomes.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service and Center for Surgical Medical Acute Care Research and Transitions, VA Medical Center, Faculty Office Tower, 510, 20th Street South, 805B, Birmingham, AL, 35294, USA.
- Department of Medicine at School of Medicine and Division of Epidemiology at School of Public Health, University of Alabama, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA.
- Department of Biostatistics, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA.
| | - Cathy Schleck
- Department of Biostatistics, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
| | - W Scott Harmsen
- Department of Biostatistics, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
| | - Adam K Jacob
- Department of Anesthesiology, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
| | - David O Warner
- Department of Anesthesiology, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
| | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
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Clarke A, Pulikottil-Jacob R, Grove A, Freeman K, Mistry H, Tsertsvadze A, Connock M, Court R, Kandala NB, Costa M, Suri G, Metcalfe D, Crowther M, Morrow S, Johnson S, Sutcliffe P. Total hip replacement and surface replacement for the treatment of pain and disability resulting from end-stage arthritis of the hip (review of technology appraisal guidance 2 and 44): systematic review and economic evaluation. Health Technol Assess 2015; 19:1-668, vii-viii. [PMID: 25634033 DOI: 10.3310/hta19100] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Total hip replacement (THR) involves the replacement of a damaged hip joint with an artificial hip prosthesis. Resurfacing arthroplasty (RS) involves replacement of the joint surface of the femoral head with a metal surface covering. OBJECTIVES To undertake clinical effectiveness and cost-effectiveness analysis of different types of THR and RS for the treatment of pain and disability in people with end-stage arthritis of the hip, in particular to compare the clinical effectiveness and cost-effectiveness of (1) different types of primary THR and RS for people in whom both procedures are suitable and (2) different types of primary THR for people who are not suitable for hip RS. DATA SOURCES Electronic databases including MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials and UK Clinical Research Network (UKCRN) Portfolio Database were searched in December 2012, with searches limited to publications from 2008 and sample sizes of ≥ 100 participants. Reference lists and websites of manufacturers and professional organisations were also screened. REVIEW METHODS Systematic reviews of the literature were undertaken to appraise the clinical effectiveness and cost-effectiveness of different types of THR and RS for people with end-stage arthritis of the hip. Included randomised controlled trials (RCTs) and systematic reviews were data extracted and risk of bias and methodological quality were independently assessed by two reviewers using the Cochrane Collaboration risk of bias tool and the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A Markov multistate model was developed for the economic evaluation of the technologies. Sensitivity analyses stratified by sex and controlled for age were carried out to assess the robustness of the results. RESULTS A total of 2469 records were screened of which 37 were included, representing 16 RCTs and eight systematic reviews. The mean post-THR Harris Hip Score measured at different follow-up times (from 6 months to 10 years) did not differ between THR groups, including between cross-linked polyethylene and traditional polyethylene cup liners (pooled mean difference 2.29, 95% confidence interval -0.88 to 5.45). Five systematic reviews reported evidence on different types of THR (cemented vs. cementless cup fixation and implant articulation materials) but these reviews were inconclusive. Eleven cost-effectiveness studies were included; four provided relevant cost and utility data for the model. Thirty registry studies were included, with no studies reporting better implant survival for RS than for all types of THR. For all analyses, mean costs for RS were higher than those for THR and mean quality-adjusted life-years (QALYs) were lower. The incremental cost-effectiveness ratio for RS was dominated by THR, that is, THR was cheaper and more effective than RS (for a lifetime horizon in the base-case analysis, the incremental cost of RS was £11,284 and the incremental QALYs were -0.0879). For all age and sex groups RS remained clearly dominated by THR. Cost-effectiveness acceptability curves showed that, for all patients, THR was almost 100% cost-effective at any willingness-to-pay level. There were age and sex differences in the populations with different types of THR and variations in revision rates (from 1.6% to 3.5% at 9 years). For the base-case analysis, for all age and sex groups and a lifetime horizon, mean costs for category E (cemented components with a polyethylene-on-ceramic articulation) were slightly lower and mean QALYs for category E were slightly higher than those for all other THR categories in both deterministic and probabilistic analyses. Hence, category E dominated the other four categories. Sensitivity analysis using an age- and sex-adjusted log-normal model demonstrated that, over a lifetime horizon and at a willingness-to-pay threshold of £20,000 per QALY, categories A and E were equally likely (50%) to be cost-effective. LIMITATIONS A large proportion of the included studies were inconclusive because of poor reporting, missing data, inconsistent results and/or great uncertainty in the treatment effect estimates. This warrants cautious interpretation of the findings. The evidence on complications was scarce, which may be because of the absence or rarity of these events or because of under-reporting. The poor reporting meant that it was not possible to explore contextual factors that might have influenced study results and also reduced the applicability of the findings to routine clinical practice in the UK. The scope of the review was limited to evidence published in English in 2008 or later, which could be interpreted as a weakness; however, systematic reviews would provide summary evidence for studies published before 2008. CONCLUSIONS Compared with THR, revision rates for RS were higher, mean costs for RS were higher and mean QALYs gained were lower; RS was dominated by THR. Similar results were obtained in the deterministic and probabilistic analyses and for all age and sex groups THR was almost 100% cost-effective at any willingness-to-pay level. Revision rates for all types of THR were low. Category A THR (cemented components with a polyethylene-on-metal articulation) was more cost-effective for older age groups. However, across all age-sex groups combined, the mean cost for category E THR (cemented components with a polyethylene-on-ceramic articulation) was slightly lower and the mean QALYs gained were slightly higher. Category E therefore dominated the other four categories. Certain types of THR appeared to confer some benefit, including larger femoral head sizes, use of a cemented cup, use of a cross-linked polyethylene cup liner and a ceramic-on-ceramic as opposed to a metal-on-polyethylene articulation. Further RCTs with long-term follow-up are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42013003924. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Aileen Clarke
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Amy Grove
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karoline Freeman
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Hema Mistry
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Martin Connock
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Matthew Costa
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Gaurav Suri
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - David Metcalfe
- Warwick Orthopaedics, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Michael Crowther
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sarah Morrow
- Oxford Medical School, University of Oxford, Oxford, UK
| | - Samantha Johnson
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Sutcliffe
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
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Liu W, Yuan S, Wei F, Yang J, Zhang Z, Zhu C, Ma J. Reliability and Validity of the Chinese Version Appropriateness Evaluation Protocol. PLoS One 2015; 10:e0136498. [PMID: 26305363 PMCID: PMC4549286 DOI: 10.1371/journal.pone.0136498] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 08/05/2015] [Indexed: 11/18/2022] Open
Abstract
Objective To adapt the Appropriateness Evaluation Protocol (AEP) to the specific settings of health care in China and to validate the Chinese version AEP (C-AEP). Methods Forward and backward translations were carried out to the original criteria. Twenty experts participated in the consultancy to form a preliminary version of the C-AEP. To ensure applicability, tests of reliability and validity were performed on 350 admissions and 3,226 hospital days of acute myocardial infraction patients and total hip replacement patients in two tertiary hospitals by two C-AEP reviewers and two physician reviewers. Overall agreement, specific agreement, and Cohen’s Kappa were calculated to compare the concordance of decisions between pairs of reviewers to test inter-rater reliability and convergent validity. The use of “overrides” and opinions of experts were recorded as measurements of content validity. Face validity was tested through collecting perspectives of nonprofessionals. Sensitivity, specificity, and predictive values were also reported. Results There are 14 admission and 24 days of care criteria in the initial version of C-AEP. Kappa coefficients indicate substantial agreement between reviewers: with regard to inter-rater reliability, Kappa (κ) coefficients are 0.746 (95% confidence interval [CI] 0.644–0.834) and 0.743 (95% CI 0.698–0.767) of admission and hospital days, respectively; for convergent validity, the κ statistics are 0.678 (95% CI 0.567–0.778) and 0.691 (95% CI 0.644–0.717), respectively. Overrides account for less than 2% of all judgments. Content validity and face validity were confirmed by experts and nonprofessionals, respectively. According to the C-AEP reviewers, 18.3% of admissions and 28.5% of inpatient days were deemed inappropriate. Conclusions The C-AEP is a reliable and valid screening tool in China’s tertiary hospitals. The prevalence of inappropriateness is substantial in our research. To reduce inappropriate utilization, further investigation is needed to elucidate the reasons and risk factors for this inappropriateness.
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Affiliation(s)
- Wenwei Liu
- Antai College of Economics and Management, Shanghai Jiao Tong University, Shanghai, China
| | - Suwei Yuan
- School of Public Health, Shanghai Jiao Tong University, Shanghai, China
| | - Fengqing Wei
- School of Public Health, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Yang
- Department of Medical Administration, Shanghai Rui Jin Hospital, Shanghai, China
| | - Zhe Zhang
- School of Public Health, Shanghai Jiao Tong University, Shanghai, China
| | - Changbin Zhu
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jin Ma
- School of Public Health, Shanghai Jiao Tong University, Shanghai, China
- * E-mail:
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Younger ASE, MacLean S, Daniels TR, Penner MJ, Wing KJ, Dunbar M, Glazebrook M. Initial hospital-related cost comparison of total ankle replacement and ankle fusion with hip and knee joint replacement. Foot Ankle Int 2015; 36:253-7. [PMID: 25367250 DOI: 10.1177/1071100714558844] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total hip and knee arthroplasty (THA and TKA) are accessible to patients with end-stage hip and knee arthritis in most health care systems. The availability of total ankle arthroplasty (TAA) to patients with end-stage ankle arthritis is often restricted because of prosthesis cost. Ankle fusion (AF) is often offered as the only alternative. Patients should have equal access to procedures that are equivalent in total cost. We compared total costs of TAA, AF, THA, and TKA for similar cohorts in a government-funded teaching hospital. METHODS A subset of 13 TAA and 13 AF patients were selected from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database, and 13 THA and 13 TKA patients were randomly selected from the Canadian Joint Replacement Registry. Total cost was estimated from operating room time, hospital stay, surgeon billing, and equipment used. RESULTS Mean total cost associated with TAA was $13,500 ± 1000 and was the same as THA ($14,500 ± 1500) and TKA ($12,500 ± 1000). Mean total cost associated with AF was significantly less at $5500 ± 500. Mean operating room time was longer, but mean hospital stay was shorter for the ankle procedures compared with THA and TKA. CONCLUSION All arthroplasties had similar total costs. Total ankle arthroplasty should not be denied based on prosthetic cost alone, as total procedure cost is equivalent to THA and TKA. We believe ankle fusion is a less expensive and preferable alternative for some patient groups.
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Affiliation(s)
- Alastair S E Younger
- Division of Distal Extremities, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada BC's Foot and Ankle Clinic, St Paul's Hospital, Vancouver, BC, Canada
| | - Scott MacLean
- Division of Orthopaedics, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada
| | - Timothy R Daniels
- Division of Orthopaedic Surgery, St Michael's Hospital and University of Toronto, Toronto, ON, Canada
| | - Murray J Penner
- Division of Distal Extremities, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada BC's Foot and Ankle Clinic, St Paul's Hospital, Vancouver, BC, Canada
| | - Kevin J Wing
- Division of Distal Extremities, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada BC's Foot and Ankle Clinic, St Paul's Hospital, Vancouver, BC, Canada
| | - Michael Dunbar
- Division of Orthopaedics, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada
| | - Mark Glazebrook
- Division of Orthopaedics, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada
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Carvalho Júnior LHD, Temponi EF, Paganini VO, Costa LP, Soares LFM, Gonçalves MBJ. Reducing the length of hospital stay after total knee arthroplasty: influence of femoral and sciatic nerve block. Rev Assoc Med Bras (1992) 2015; 61:40-3. [PMID: 25909207 DOI: 10.1590/1806-9282.61.01.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/03/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE the aim of this study is to evaluate the change in length of hospital stay postoperatively for Total Knee Arthroplasty after using femoral and sciatic nerve block. MATERIALS AND METHODS the medical records of 287 patients were evaluated, taking into account the number of hours of admission, the percentage and the reason for re-hospitalization within 30 days, as well as associated complications. All patients were divided into two groups according or not to whether they were admitted to ICU or not. During the years 2009 and 2010, isolated spinal anesthesia was the method used in the procedure. From 2011 on, femoral and sciatic nerve blocking was introduced. RESULTS between the years 2009 and 2012, the average length of stay ranged from 74 hours in 2009 to 75.2 hours in 2010. The average length of stay in 2011 was 56.52 hours and 53.72 hours in 2012, all in the group of patients who did not remain in the ICU postoperatively. In the same period, among those in the group that needed ICU admission, the average length of stay was 138.7 hours in 2009, 90.25 hours in 2010, 79.8 hours in 2011, and 52.91 hours in 2012. During 2009 and 2010, the rate of re-hospitalization was 0%, while in 2011 and 2012, were 3.44% and 1%, respectively. CONCLUSION according to this study, the use of femoral and sciatic nerve blocking after total knee arthroplasty allowed significant reduction in hospital stay.
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Affiliation(s)
| | - Eduardo Frois Temponi
- Orthopedics and Traumatology Service, Madre Teresa Hospital, Belo Horizonte, MG, Brazil
| | | | - Lincoln Paiva Costa
- Orthopedics and Traumatology Service, Madre Teresa Hospital, Belo Horizonte, MG, Brazil
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Singh JA, Lewallen DG. Increasing obesity and comorbidity in patients undergoing primary total hip arthroplasty in the U.S.: a 13-year study of time trends. BMC Musculoskelet Disord 2014; 15:441. [PMID: 25519434 PMCID: PMC4302153 DOI: 10.1186/1471-2474-15-441] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 12/10/2014] [Indexed: 12/21/2022] Open
Abstract
Background Few, if any data are available are available regarding the time-trends in characteristics of patients who have undergone primary THA. Our objective was to examine the time-trends in key demographic and clinical characteristics of patients undergoing primary total hip arthroplasty (THA). Methods We used the data from the Mayo Clinic Total Joint Registry from 1993–2005 to examine the time-trends in demographics (age, body mass index (BMI)), medical (Deyo-Charlson index) and psychological comorbidity (anxiety, depression) and underlying diagnosis of patients undergoing primary THA. Chi-square test and analysis for variance were used. Multivariable-adjusted logistic regression (age, sex, comorbidity-adjusted) compared 1993–95 to other study periods. Odds ratio (OR) and 95% confidence interval (CI) are presented. Results The primary THA cohort consisted of 6,168 patients with 52% women. In unadjusted analyses, compared to 1993–95, significantly more patients (by >2-times for most) in 2002–05 had: BMI ≥ 40, 2.3% vs. 6.3%; depression, 4.1% vs. 9.8%; and anxiety, 3.4% vs. 5.7%; and significantly fewer had an underlying diagnosis of rheumatoid/inflammatory arthritis, 3.7% vs. 1.5% (p ≤ 0.01 for all). In multivariable-adjusted models, compared to 1993–95, significantly more patients in 2003–05 had (all p-values ≤ 0.01): BMI ≥ 40, OR, 2.79 (95% CI: 1.85, 4.22); Deyo-Charlson Index ≥ 3, 1.32 (1.07, 1.63); depression, 2.25 (1.66, 3.05); and anxiety, 1.71 (1.19, 2.15). Respectively, fewer patients had a diagnosis of RA/inflammatory arthritis: 0.28 (0.17, 0.46; p < 0.01). Over the 13-year study period, Deyo-Charlson index increased by 22% (0.9 to 1.1) and the mean age decreased by 0.7 years (65.0 to 64.3) (p < 0.01 for both). Conclusions Obesity, medical and psychological comorbidity increased and the underlying diagnosis of RA/inflammatory arthritis decreased rapidly in primary THA patients over 13-years. Our cohort characteristics are similar to previously described characteristics of national U.S. cohort, suggesting that these trends may be national rather than local trends. This is important information for policy makers to take into account for resource allocation. Studies of THA outcomes and utilization should take these rapidly changing patient characteristics into account.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center, Birmingham, AL, USA.
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27
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Jiang SL, Schairer WW, Bozic KJ. Increased rates of periprosthetic joint infection in patients with cirrhosis undergoing total joint arthroplasty. Clin Orthop Relat Res 2014; 472:2483-91. [PMID: 24711129 PMCID: PMC4079852 DOI: 10.1007/s11999-014-3593-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 03/19/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Total joint arthroplasty (TJA) is becoming more prevalent, with additional increases in procedure rates expected as the US population ages. Small series have suggested increased risk of periprosthetic joint infections in patients with liver cirrhosis after TJA. However, the rates of periprosthetic joint infections and use of TJA for patients with cirrhosis have not been evaluated on a larger scale. QUESTIONS/PURPOSES The purposes of this study were to (1) measure the rate of periprosthetic joint infections after THAs and TKAs in patients with cirrhosis of the liver; (2) assess mortality, length of hospital stay, readmission rates, and other clinical factors among patients with cirrhosis who have had a TJA; and (3) evaluate the use of TJA in the United States among patients with liver cirrhosis during the past decade. METHODS National and state-level databases were used to identify patients with and without liver cirrhosis who underwent TJAs. The rate of periprosthetic joint infections within 6 months was assessed using the Statewide Inpatient Database, which identified 306,946 patients undergoing THAs (0.3% with cirrhosis) and 573,840 patients undergoing TKAs (0.2% with cirrhosis). To evaluate trends in the use of TJAs, 16,634 patients with cirrhosis who underwent TJAs were identified from the Nationwide Inpatient Sample from 2000 to 2010. RESULTS Periprosthetic joint infections after THA were more common in patients with cirrhosis for hip fracture (6.3% versus 1.1%; hazard ratio [HR], 5.8; p < 0.001) and nonhip fracture diagnoses (3.7% versus 0.7%; HR, 5.4; p < 0.001). Periprosthetic joint infections were more common after TKA in patients with cirrhosis (2.7% versus 0.8%; HR, 3.4; p < 0.001). Use of TJA increased faster for patients with cirrhosis than for patients without cirrhosis for THAs (140% versus 80%; p = 0.011) and TKAs (213% versus 128%; p < 0.001), and also increased faster than the general increase in use of TJAs. CONCLUSIONS Periprosthetic joint infections were more common among patients with cirrhosis who had TJAs. Additionally, patients with cirrhosis had longer length of hospital stay, increased costs, and higher rates of mortality, readmission, and reoperation. Finally, national use of TJAs for patients with cirrhosis has increased during the past decade. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shirley L. Jiang
- Department of Orthopaedic Surgery and Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 500 Parnassus Avenue, MU 320W, San Francisco, CA 94143-0728 USA
| | - William W. Schairer
- Department of Orthopaedic Surgery and Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 500 Parnassus Avenue, MU 320W, San Francisco, CA 94143-0728 USA
| | - Kevin J. Bozic
- Department of Orthopaedic Surgery and Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 500 Parnassus Avenue, MU 320W, San Francisco, CA 94143-0728 USA
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Berstock JR, Beswick AD, Lenguerrand E, Whitehouse MR, Blom AW. Mortality after total hip replacement surgery: A systematic review. Bone Joint Res 2014; 3:175-82. [PMID: 24894596 PMCID: PMC4054013 DOI: 10.1302/2046-3758.36.2000239] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Total hip replacement causes a short-term increase
in the risk of mortality. It is important to quantify this and to identify
modifiable risk factors so that the risk of post-operative mortality
can be minimised. We performed a systematic review and critical
evaluation of the current literature on the topic. We identified
32 studies published over the last 10 years which provide either
30-day or 90-day mortality data. We estimate the pooled incidence
of mortality during the first 30 and 90 days following hip replacement
to be 0.30% (95% CI 0.22 to 0.38) and 0.65% (95% CI 0.50 to 0.81),
respectively. We found strong evidence of a temporal trend towards
reducing mortality rates despite increasingly co-morbid patients.
The risk factors for early mortality most commonly identified are
increasing age, male gender and co-morbid conditions, particularly
cardiovascular disease. Cardiovascular complications appear to have
overtaken fatal pulmonary emboli as the leading cause of death after
hip replacement. Cite this article: Bone Joint Res 2014;3:175–82.
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Affiliation(s)
- J R Berstock
- Southmead Hospital, Musculoskeletal Research Unit, AOC (Lower Level), Westbury-on-Trym, Bristol BS10 5NB, UK
| | - A D Beswick
- Southmead Hospital, Musculoskeletal Research Unit, AOC (Lower Level), Westbury-on-Trym, Bristol BS10 5NB, UK
| | - E Lenguerrand
- Southmead Hospital, Musculoskeletal Research Unit, AOC (Lower Level), Westbury-on-Trym, Bristol BS10 5NB, UK
| | - M R Whitehouse
- Southmead Hospital, Musculoskeletal Research Unit, AOC (Lower Level), Westbury-on-Trym, Bristol BS10 5NB, UK
| | - A W Blom
- Southmead Hospital, Musculoskeletal Research Unit, AOC (Lower Level), Westbury-on-Trym, Bristol BS10 5NB, UK
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The association between comorbidity and length of hospital stay and costs in total hip arthroplasty patients: a systematic review. J Arthroplasty 2014; 29:1009-14. [PMID: 24287128 DOI: 10.1016/j.arth.2013.10.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 10/03/2013] [Accepted: 10/06/2013] [Indexed: 02/01/2023] Open
Abstract
We performed a systematic review on the relationship between comorbidity and length of hospital stay (LOS) and hospital costs (HC). Electronic databases were systematically searched for relevant studies, conducting methodological quality assessment and best-evidence synthesis: 317 articles were identified, 10 of which fit the inclusion criteria; nine studies determined the relationship between comorbidity and LOS, with eight reporting a positive correlation; five studies were considered to be of high quality, four of which found a positive correlation; two studies analyzed the relationship between comorbidity and HC and reported significantly higher HC for patients with comorbidities, and were considered to be of high quality. In conclusion, there is limited evidence that patient comorbidity has a positive correlation with LOS and HC.
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Webster F, Bremner S, Katz J, Watt-Watson J, Kennedy D, Sawhney M, McCartney C. Patients' perceptions of joint replacement care in a changing healthcare system: a qualitative study. Healthc Policy 2014; 9:55-66. [PMID: 24726074 PMCID: PMC3999571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Ontario has introduced strategies over the past decade to reduce wait times and length of stay and improve access to physiotherapy for orthopaedic and other patients. The aim of this study is to explore patients' experiences of joint replacement care during a significant system change in their care setting. METHODS A secondary analysis was done on semi-structured qualitative interviews that were conducted in 2009 with 12 individuals who had undergone at least two hip or knee replacements five years apart at a specialized orthopaedic centre in Ontario, Canada. Interview transcripts were coded and then organized into themes. RESULTS Although the original study aimed to capture participants' experiences with changes in anaesthetic technique between their first and second joint replacements, the participants described several unrelated differences in the care they received during this period. For example, participants had difficulty obtaining a referral to an orthopaedic surgeon from their family physician. They also noted that the hospital stay and in-hospital physiotherapy they received were shorter after the second joint replacement surgery. They identified guidance from physiotherapists as an important component of their recovery, but sometimes had difficulty arranging physiotherapy after hospital discharge following their most recent surgery. CONCLUSIONS The changes described between the first and second joint replacements provide the participants' perspective on the impact of policy changes on wait times, reduced lengths of hospital stay and physiotherapy access. The impact of these policy changes, often made in an attempt to improve access to care, had an unintended and detrimental effect on participants' perceptions and experiences of the quality of care provided.
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Affiliation(s)
- Fiona Webster
- Department of Family and Community Medicine, University of Toronto, Toronto, ON
| | - Samantha Bremner
- Michael G. DeGroote School of Medicine, McMaster University Hamilton, ON
| | - Joel Katz
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, ON
| | - Judy Watt-Watson
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON
| | - Deborah Kennedy
- Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - Mona Sawhney
- Acute Pain Service, North York General Hospital Toronto, ON
| | - Colin McCartney
- Department of Anaesthesia, Faculty of Medicine, University of Toronto, Toronto, ON
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Volume associations in total hip arthroplasty: a nationwide Taiwan population-based study. J Arthroplasty 2013; 28:1834-8. [PMID: 23623565 DOI: 10.1016/j.arth.2013.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 02/06/2013] [Accepted: 03/16/2013] [Indexed: 02/01/2023] Open
Abstract
This cohort study retrospectively analyzed 78,364 THAs performed from 1998 to 2009. The mean hospital charge for all THAs performed during the study period was $4,131.9 dollars. The average hospital charges for high-volume hospitals and surgeons were 6% and 7% lower, respectively, than those for low-volume hospitals and surgeons. Analysis by propensity score matching showed that hospital charges significantly differed between THA procedures performed by high- and low-volume hospitals ($3,285.8 dollars versus $4,816.2 dollars, respectively) and between THA procedures performed by high- and low-volume surgeons, ($3,438.5 dollars versus $4,404.7 dollars, respectively) (P < 0.001). The data indicate that analysis and emulation of the treatment strategies used by high-volume hospitals and by high-volume surgeons may reduce overall hospital charges.
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Dahl OE, Gudmundsen TE, Pripp AH, Aanesen JJ. Clinical Venous Thromboembolism Following Joint Surgery. Clin Appl Thromb Hemost 2013; 20:117-23. [DOI: 10.1177/1076029613499820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We describe annual incidences and 6-month postoperative patterns of clinical venous thromboembolism (VTE) in 9078 patients undergoing major joint surgery in a Scandinavian hospital. In cohort I (1989-1999), low-molecular-weight heparin thromboprophylaxis for 7 to 10 days was uniformly introduced, 5-week thromboprophylaxis becoming routine after total hip replacement (THR), partially applied after hip fracture surgery (HFS), but not used after total knee replacement (TKR) thereafter (2003-2011; cohort II). Mean annual VTE incidence was lower in cohort II than in cohort I after THR and HFS but not after TKR. In cohort I, the cumulative VTE incidence increased sharply during the first 5 postoperative weeks in all groups, subsequently plateauing up to 6 months postsurgery. In cohort II, this incidence remained low and stable during 5 weeks post-THR, rising gradually up to 6 months, with a comparable but less pronounced pattern following HFS but not TKR. In conclusion, the VTE risk after major joint surgery seems to persist after 5- and 1-week prophylaxis in patients undergoing hip surgery and TKR, respectively.
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Affiliation(s)
- Ola E. Dahl
- Centre of Medical Science, Education and Innovation, Innlandet Hospital Trust, Brumunddal, Norway
- Thrombosis Research Institute, London, UK
| | - Tor E. Gudmundsen
- Department of Medical Imaging, Vestre Viken Hospital Trust, Drammen Hospital, Drammen, Norway
- Buskerud University College, Drammen, Norway
| | - Are H. Pripp
- Biostatistics Unit, Oslo University Hospital, Oslo, Norway
| | - Joakim J. Aanesen
- Department of Medical Imaging, Vestre Viken Hospital Trust, Drammen Hospital, Drammen, Norway
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Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, Tobias JH, Vernon K, Blom AW. 90-day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 2013; 382:1097-104. [PMID: 24075049 DOI: 10.1016/s0140-6736(13)61749-3] [Citation(s) in RCA: 211] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Death within 90 days after total hip replacement is rare but might be avoidable dependent on patient and treatment factors. We assessed whether a secular decrease in death caused by hip replacement has occurred in England and Wales and whether modifiable perioperative factors exist that could reduce deaths. METHODS We took data about hip replacements done in England and Wales between April, 2003, and December, 2011, from the National Joint Registry for England and Wales. Patient identifiers were used to link these data to the national mortality database and the Hospital Episode Statistics database to obtain details of death, sociodemographics, and comorbidity. We assessed mortality within 90 days of operation by Kaplan-Meier analysis and assessed the role of patient and treatment factors by Cox proportional hazards model. FINDINGS 409,096 primary hip replacements were done to treat osteoarthritis. 1743 patients died within 90 days of surgery during 8 years, with a substantial secular decrease in mortality, from 0·56% in 2003 to 0·29% in 2011, even after adjustment for age, sex, and comorbidity. Several modifiable clinical factors were associated with decreased mortality according to an adjusted model: posterior surgical approach (hazard ratio [HR] 0·82, 95% CI 0·73-0·92; p=0·001), mechanical thromboprophylaxis (0·85, 0·74-0·99; p=0·036), chemical thromboprophylaxis with heparin with or without aspirin (0·79, 0·66-0·93; p=0·005), and spinal versus general anaesthetic (0·85, 0·74-0·97; p=0·019). Type of prosthesis was unrelated to mortality. Being overweight was associated with lower mortality (0·76, 0·62-0·92; p=0·006). INTERPRETATION Postoperative mortality after hip joint replacement has fallen substantially. Widespread adoption of four simple clinical management strategies (posterior surgical approach, mechanical and chemical prophylaxis, and spinal anaesthesia) could, if causally related, reduce mortality further. FUNDING National Joint Registry for England and Wales.
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Affiliation(s)
- Linda P Hunt
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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Jørgensen C, Kehlet H. Role of patient characteristics for fast-track hip and knee arthroplasty. Br J Anaesth 2013; 110:972-80. [DOI: 10.1093/bja/aes505] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Body mass index as predictor of health-related quality-of-life changes after total hip arthroplasty: a cross-over study. J Arthroplasty 2013; 28:666-70. [PMID: 23142451 DOI: 10.1016/j.arth.2012.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 06/20/2012] [Accepted: 07/10/2012] [Indexed: 02/01/2023] Open
Abstract
The objective of this study was to examine the contribution of patient weight and other preoperative variables to improvements in the general physical health of patients undergoing total hip arthroplasty (THA). Data were prospectively collected on 63 THA patients (28 males and 35 females). The primary outcome measure was the improvement in general health (Short Form-12 Health Survey questionnaire) at three months post-THA. Patients with body mass index >28kg/m(2) showed greater improvements in function and in the physical component of general health after THA. Stepwise regression analyses revealed that the BMI and WOMAC general index were independent and significant predictors of physical function and together explained 34.2% of the variance in physical function scores. These findings suggest that the body mass index before surgery and improvements in hip function are relevant contributors to post-THA improvements in general health.
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Trends and geographical variation of primary hip and knee joint replacement in Germany. Osteoarthritis Cartilage 2013; 21:279-88. [PMID: 23220558 DOI: 10.1016/j.joca.2012.11.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 10/20/2012] [Accepted: 11/19/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Considerable variation in total hip replacement and total knee replacement (THR/TKR) between regions has been described. The aim of this study was to explore geographical variation in THR and TKR in Germany and to analyse potentially explanatory variables. METHOD We used data of Germany's largest statutory health insurer. Between 2005 and 2009 451,108 THR and 335,022 TKR were performed. Age-standardised joint replacement rates were calculated for 16 federal states and 407 counties. We performed cluster (Moran's I) and spatial error regression analyses including regional deprivation, osteoarthritis rate, urbanity and number of orthopaedic specialists as dependent variables on county level. RESULTS In 2009 the overall age-standardised and crude rates were 148.9 (95% CI (confidence interval) 147.6-151.1) and 290.2 for THR, and 132.5 (95% CI 131.3-133.6) and 232.7 for TKR. Between counties THR rates differed by factor 2 (106.1-215.8) and showed significant clusters with high utilisation in South and Northwest Germany. TKR rates differed by factor 3.2 (69.1-219.5) and were also high in South Germany whereas almost all areas in East Germany showed low replacement rates. Differences were pronounced when restricting the analysis to cases with an indication of osteoarthritis. All tested predictors could be identified as significant explanatory variables (each P < 0.001). CONCLUSION This study proofed considerable and consistent geographic variation of THR and TKR in Germany. Thereby relevant explanatory factors were identified. These results may foster the discussion and future research in health services which should include areas of patients' and doctors' expectation, financial aspects and an outcome-based definition of appropriate supply.
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Villanueva-Martınez M, Hernandez-Barrera V, Chana-Rodríguez F, Rojo-Manaute J, Rıos-Luna A, San Roman Montero J, Gil-de-Miguel A, Jimenez-Garcia R. Trends in incidence and outcomes of revision total hip arthroplasty in Spain: a population based study. BMC Musculoskelet Disord 2012; 13:37. [PMID: 22429798 PMCID: PMC3349558 DOI: 10.1186/1471-2474-13-37] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 03/19/2012] [Indexed: 12/02/2022] Open
Abstract
Background To analyze changes in incidence and outcomes of patients undergoing revision total hip arthroplasty (RTHA) over an 8-year study period in Spain. Methods We selected all surgical admissions in individuals aged ≥ 40 years who underwent RTHA (ICD-9-CM procedure code 81.53) between 2001 and 2008 from the Spanish National Hospital Discharge Database. Age- and sex-specific incidence rates, Charlson co-morbidity index, length of stay (LOS), costs and in-hospital mortality (IHM) were estimated for each year. Multivariate analyses were conducted to asses time trends. Results 32, 280 discharges of patients (13, 391 men/18, 889 women) having undergone RTHA were identified. Overall crude incidence showed a small but significant increase from 20.2 to 21.8 RTHA per 100, 000 inhabitants from 2001 to 2008 (p < 0.01). The incidence increased for men (17.7 to 19.8 in 2008) but did not vary for women (22.3 in 2001 and 22.2 in 2008). Greater increments were observed in patients older than 84 years and in the age group 75-84. In 2001, 19% of RTHA patients had a Charlson Index ≥ 1 and this proportion rose to 24.6% in 2008 (p < 0.001). The ratio RTHA/THA remained stable and around 20% in Spain along the entire period The crude overall in-hospital mortality (IHM) increased from 1.16% in 2001 to 1.77% (p = 0.025) in 2008. For both sexes the risk of death was higher with age, with the highest mortality rates found among those aged 85 or over. After multivariate analysis no change was observed in IHM over time. The mean inflation adjusted cost per patient increased by 78.3%, from 9, 375 to 16, 715 Euros from 2001 to 2008. After controlling for possible confounders using Poisson regression models, we observed that the incidence of RTHA hospitalizations significantly increased for men and women over the period 2001 to 2008 (IRR 1.10, 95% CI 1.03-1.18 and 1.08, 95% CI 1.02-1.14 respectively). Conclusions The crude incidence of RTHA in Spain showed a small but significant increase from 2001 to 2008 with concomitant reductions in LOS, significant increase in co-morbidities and cost per patient.
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Reduced length of stay following hip and knee arthroplasty in Denmark 2000-2009: from research to implementation. Arch Orthop Trauma Surg 2012; 132:101-4. [PMID: 21947286 DOI: 10.1007/s00402-011-1396-0] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Fast-track surgery is the combination of optimized clinical and organizational factors aiming at reducing convalescence and perioperative morbidity including the functional recovery resulting in reduced hospitalization. As the previous nationwide studies have demonstrated substantial variations in length of stay (LOS) following standardized operations such as total hip and knee arthroplasty (THA and TKA), this nationwide study was undertaken to evaluate the implementation process of fast-track THA and TKA in Denmark. MATERIALS AND METHODS All hospitals in Denmark report to the National Patient Registry, linking the type of surgery and LOS with a unique individual social security number. This study is based on primary THA and TKA from a 5.5 million population from 2000 to the end of 2009. RESULTS The number of performed primary unilateral THA and TKA has increased from around 7,200 in 2000 to 13,800 in 2009 with a concomitant reduction in LOS from median 10-11 days in 2000 to 4 days in 2009. CONCLUSION Fast-track surgery has been successfully implemented in the orthopedic departments in Denmark through a multi-disciplinary educational and multi-institutional effort. These implementation principles may be transferred to other countries and other specialties.
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