Thirty-day readmission rates in orthopedics: a systematic review and meta-analysis

Utility of Machine Learning, Natural Language Processing, and Artificial Intelligence in Predicting Hospital Readmissions After Orthopaedic Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Numerous applications and strategies have been utilized to help assess the trends and patterns of readmissions after orthopaedic surgery in an attempt to extrapolate possible risk factors and causative agents. The aim of this work is to systematically summarize the available literature on the extent to which natural language processing, machine learning, and artificial intelligence (AI) can help improve the predictability of hospital readmissions after orthopaedic and spine surgeries.

METHODS

This is a systematic review and meta-analysis. PubMed, Embase and Google Scholar were searched, up until August 30, 2023, for studies that explore the use of AI, natural language processing, and machine learning tools for the prediction of readmission rates after orthopedic procedures. Data regarding surgery type, patient population, readmission outcomes, advanced models utilized, comparison methods, predictor sets, the inclusion of perioperative predictors, validation method, size of training and testing sample, accuracy, and receiver operating characteristics (C-statistic), among other factors, were extracted and assessed.

RESULTS

A total of 26 studies were included in our final dataset. The overall summary C-statistic showed a mean of 0.71 across all models, indicating a reasonable level of predictiveness. A total of 15 articles (57%) were attributed to the spine, making it the most commonly explored orthopaedic field in our study. When comparing accuracy of prediction models between different fields, models predicting readmissions after hip/knee arthroplasty procedures had a higher prediction accuracy (mean C-statistic = 0.79) than spine (mean C-statistic = 0.7) and shoulder (mean C-statistic = 0.67). In addition, models that used single institution data, and those that included intraoperative and/or postoperative outcomes, had a higher mean C-statistic than those utilizing other data sources, and that include only preoperative predictors. According to the Prediction model Risk of Bias Assessment Tool, the majority of the articles in our study had a high risk of bias.

CONCLUSION

AI tools perform reasonably well in predicting readmissions after orthopaedic procedures. Future work should focus on standardizing study methodologies and designs, and improving the data analysis process, in an attempt to produce more reliable and tangible results.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Advanced Multi-Layer Watertight Closure versus Conventional Closure in Total Hip and Knee Replacement Surgery

Background

In total joint replacement procedures, surgeons have increasingly adopted advanced multi-layer, watertight closure. The objective of the study was to compare the clinical and economic outcomes for advanced multi-layer, watertight closure patients to those with conventional closure with sutures and skin staples.

Methods

Patients aged ≥18 years were included in the study if they underwent total joint arthroplasty of the hip or knee as an elective, primary, inpatient procedure between January 2014 and March 2019. Cohorts having advanced multi-layer, watertight closure or conventional closure were compared using multivariable regression analysis of surgical site infections, length of stay, operating room time, procedure time, discharge status, readmissions, reoperations, and hospital emergency department visits.

Results

A total of 1828 patients received at least one total hip or knee replacement, of which 434 (23.7%) had advanced multi-layer, watertight closure and 1394 (76.3%) had conventional closure. Unadjusted time to readmission, when occurring, was considerably longer following advanced multi-layer, watertight closure (89.9 vs 51.1 days, p < 0.0001), and a lower proportion of the advanced multi-layer, watertight closure cohort required reoperation within 90 days (0.0% vs 2.6%, p < 0.0001). Adjusted mean hospital length of stay was approximately half of a day shorter for advanced multi-layer, watertight closure patients (1.10 vs 1.65 days; p < 0.001), and they were also more likely to be discharged to home (Odds Ratio: 4.61; p = 0.002).

Conclusion

Among patients undergoing total hip and knee arthroplasty in a highly optimized real-world clinical practice, advanced multi-layer, watertight closure was associated with significantly shorter inpatient length of stay and increased likelihood of being discharged to home compared with conventional closure. These findings suggest that advanced multi-layer, watertight closure is a valuable component of an optimal workflow for total hip or knee replacement, and may be especially valuable for high-risk patients.

Evaluating the risk of return to the operating room across all elective orthopaedic procedures

BACKGROUND

Although elective procedures have life-changing potential, all surgeries come with an inherent risk of reoperation. There is a gap in knowledge investigating the risk of reoperation across orthopaedics. We aimed to identify the elective orthopaedic procedures with the highest rate of unplanned reoperation and the reasons for these procedures having such high reoperation rates.

METHODS

Patients in the NSQIP database were identified using CPT and ICD-10 codes. We isolated 612,815 orthopaedics procedures from 2018 to 2020 and identified the 10 CPT codes with the greatest rate of unplanned return to the operating room. For each index procedure, we identified the ICD-10 codes for the reoperation procedure and categorized them into infection, mechanical failure, fracture, wound disruption, hematoma or seroma, nerve pathology, other, and unspecified.

RESULTS

Below knee amputation (BKA) (CPT 27880) had the highest reoperation rate of 6.92% (37 of 535 patients). Posterior-approach thoracic (5.86%) or cervical (4.14%) arthrodesis and cervical laminectomy (3.85%), revision total hip arthroplasty (5.23%), conversion to total hip arthroplasty (4.33%), and revision shoulder arthroplasty (4.22%) were among the remaining highest reoperation rates. The overall leading causes of reoperation were infection (30.1%), mechanical failure (21.1%), and hematoma or seroma (9.4%) for the 10 procedures with the highest reoperation rates.

CONCLUSIONS

This study successfully identified the elective orthopaedic procedures with the highest 30-day return to OR rates. These include BKA, posterior thoracic and cervical spinal arthrodesis, revision hip arthroplasty, revision total shoulder arthroplasty, and cervical laminectomy. With this data, we can identify areas across orthopaedics in which revising protocols may improve patient outcomes and limit the burden of reoperations on patients and the healthcare system. Future studies should focus on the long-term physical and financial impact that these reoperations may have on patients and hospital systems.

LEVEL OF CLINICAL EVIDENCE

IV.

Risk Factors for Hospital Readmission Following Noncardiac Surgery: International Cohort Study

Objective

To determine timing and risk factors associated with readmission within 30 days of discharge following noncardiac surgery.

Background

Hospital readmission after noncardiac surgery is costly. Data on the drivers of readmission have largely been derived from single-center studies focused on a single surgical procedure with uncertainty regarding generalizability.

Methods

We undertook an international (28 centers, 14 countries) prospective cohort study of a representative sample of adults ≥45 years of age who underwent noncardiac surgery. Risk factors for readmission were assessed using Cox regression (ClinicalTrials.gov, NCT00512109).

Results

Of 36,657 eligible participants, 2744 (7.5%; 95% confidence interval [CI], 7.2-7.8) were readmitted within 30 days of discharge. Rates of readmission were highest in the first 7 days after discharge and declined over the follow-up period. Multivariable analyses demonstrated that 9 baseline characteristics (eg, cancer treatment in past 6 months; adjusted hazard ratio [HR], 1.44; 95% CI, 1.30-1.59), 5 baseline laboratory and physical measures (eg, estimated glomerular filtration rate or on dialysis; HR, 1.47; 95% CI, 1.24-1.75), 7 surgery types (eg, general surgery; HR, 1.86; 95% CI, 1.61-2.16), 5 index hospitalization events (eg, stroke; HR, 2.21; 95% CI, 1.24-3.94), and 3 other factors (eg, discharge to nursing home; HR, 1.61; 95% CI, 1.33-1.95) were associated with readmission.

Conclusions

Readmission following noncardiac surgery is common (1 in 13 patients). We identified perioperative risk factors associated with 30-day readmission that can help frontline clinicians identify which patients are at the highest risk of readmission and target them for preventive measures.

Use of interrupted time-series analyses in evaluating health economic outcomes following implementation of multilayer water-tight wound closure in a primary total joint arthroplasty population

Aim: Total joint arthroplasty (TJA) with multi-layer, watertight closure (MLWC) using knotless barbed suture and 2-octyl cyanoacrylate plus polymer mesh tape was compared with conventional closure (CC) using Vicryl™ sutures and staples. Patients & methods: Electronic medical records of patients undergoing TJA (1574: total knee arthroplasty; 580: total hip arthroplasty; 13: unknown) from a single surgeon at a US hospital (CC 2011 to 2013; MLWC 2015 to 2020) were reviewed. Outcomes were length of stay (LOS), discharge to skilled nursing facility (SNF), 90-day surgical site infection (SSI) and 90-day readmission. Logistic regression controlled for baseline characteristics. Adjusted interrupted time series (ITS) analyses accounted for decreasing trends in LOS and SNF discharge over time. Results: Among 2167 TJA cases (mean [standard deviation] age 66.0 [9.7] years, 53.3% female), 906 received CC and 1261 received MLWC. Bivariate analysis showed no statistically significant differences in 90-day SSI rates; however, MLWC patients had 60% lower 90-day readmission rates (1.5 vs 3.8%, p < 0.05), 44% lower LOS (1.4 vs 2.5 days, p < 0.05) and 40% lower discharge rates to a skilled care facility (8.5 vs 14.1%, p < 0.05). Multivariable analyses showed CC patients were 2.45-times more likely to be readmitted within 90 days, 1.88-times more likely to be discharged to SNF and had 1.67-times longer LOS compared with MLWC. ITS analyses showed a sharp decline in LOS (0.9 days) and discharge to SNF (5.6% incidence) after implementation of MLWC, followed by no further changes for the remainder of the study period. Conclusion: MLWC was associated with ≥40% reduction in 90-day readmission, LOS and SNF discharge compared with TJA CC. LOS and discharge rate to SNF declined sharply after the implementation of MLWC.

Racial Disparities in 30-day Readmission After Orthopaedic Surgery: A 5-year National Surgical Quality Improvement Program Database Analysis

BACKGROUND

Readmission rate after surgery is an important outcome measure in revealing disparities. This study aimed to examine how 30-day readmission rates and causes of readmission differ by race and specific injury areas within orthopaedic surgery.

METHODS

The American College of Surgeon-National Surgical Quality Improvement Program database was queried for orthopaedic procedures from 2015 to 2019. Patients were stratified by self-reported race. Procedures were stratified using current procedural terminology codes corresponding to given injury areas. Multiple logistic regression was done to evaluate associations between race and all-cause readmission risk, and risk of readmission due to specific causes.

RESULTS

Of 780,043 orthopaedic patients, the overall 30-day readmission rate was 4.18%. Black and Asian patients were at greater (OR = 1.18, P < 0.01) and lesser (OR = 0.76, P < 0.01) risk for readmission than White patients, respectively. Black patients were more likely to be readmitted for deep surgical site infection (OR = 1.25, P = 0.03), PE (OR = 1.64, P < 0.01), or wound disruption (OR = 1.45, P < 0.01). For all races, all-cause readmission was highest after spine procedures and lowest after hand/wrist procedures.

CONCLUSIONS

Black patients were at greater risk for overall, spine, shoulder/elbow, hand/wrist, and hip/knee all-cause readmission. Asian patients were at lower risk for overall, spine, hand/wrist, and hip/knee surgery all-cause readmission. Our findings can identify complications that should be more carefully monitored in certain patient populations.

Complications in Hand Surgery During Early Independent Practice: A Single Surgeon's 5-Year Experience

BACKGROUND

The objective of this study was to understand the frequency and types of complications, and the associated postoperative outcomes within the first 5 years of practice after hand and upper extremity surgery fellowship.

METHODS

This was a retrospective observational study of all patients seen and surgically treated by a single surgeon at a single institution from August 2014 to September 2019. This corresponded to the first 5 years of practice after fellowship. Data collected included patient demographics, perioperative data, complication type, and outcome of the complication (better/same/worse than preoperative status). Complications were classified using the Clavien-Dindo system and a unique, self-derived system.

RESULTS

In total, 3301 surgeries were performed during the first 5 years of practice. The overall complication rate was 7.9% (261 complications from 239 patients). The 30-day complication rate was 5.2% (171/3301). Eleven (4.2%) of the 261 complications occurred intraoperatively. The total number of complications significantly declined during the first 5 years of practice as follows: 74, 71, 46, 37, and 33 (P = .010, R2 = .92). Hand and wrist were the most frequent anatomic locations involved and bone pathology was the predominant indication.

CONCLUSION

The overall surgical complication rate for hand and upper extremity surgery was 7.9%, with a 30-day complication rate of 5.2% (171/3301). The rate of complications after fellowship declined over the first 5 years of independent practice. Superficial infections were the most common complication. More than 90% of patients ultimately improved after addressing the complication.

LEVEL OF EVIDENCE

IV.

Retrospective Analysis of Causes and Risk Factors of 30-Day Readmission After Spine Surgery for Thoracolumbar Trauma

STUDY DESIGN

Retrospective Case Series.

OBJECTIVE

This study aims to evaluate readmission rates, risk factors, and reason for unplanned 30-day readmissions after thoracolumbar spine trauma surgery.

METHODS

A retrospective chart review was conducted for patients undergoing operative treatment for thoracic or lumbar trauma with open or minimally invasive surgical approach at a Level 1 urban trauma center. Patients were divided into two groups based on 30-day readmission status. Reason for readmission, reoperation rates, injury type, trauma severity, and incidence of polytrauma were compared between the two groups.

RESULTS

A total of 312 patients, 69.9% male with an average age of 47 ± 19 years were included. The readmitted group included 16 patients (5.1%) of which 9 (56%) were readmitted for medical complications and 7 for surgical complications. Wound complications (31.3% of readmissions) were the most common cause of readmission, followed by non-wound related sepsis (18.9% of readmissions). A total of 6 patients (37.5%) required reoperation; 2 instrumentation failures underwent revision surgery, and 4 wound complications underwent irrigation and debridement. Patients with higher Injury Severity Scale (ISS) were more likely to be readmitted (27.8% vs 22.1%, P = .045). Concomitant lower limb surgery increased odds of readmission (OR, 4.40; 95% CI, 1.10-17.83; P = .037).

CONCLUSION

Spine trauma 30-day readmission rate was 5.1%, comparable to those reported in the elective spine surgery literature. Readmitted patients were more likely to sustain concomitant operative lower limb trauma. Wound complications were the most common cause of readmission, and almost half of the patients were readmitted due to surgery-related complications.

Weekend Admission Increases Risk of Readmissions Following Elective Cervical Spinal Fusion

Objective: The “weekend effect” occurs when patients cared for during weekends versus weekdays experience worse outcomes. But reasons for this effect are unclear, especially amongst patients undergoing elective cervical spinal fusion (ECSF). Our aim was to analyze whether index weekend admission affects 30- and 90-day readmission rates post-ECSF.Methods: All ECSF patients > 18 years were retrospectively identified from the 2016–2018 Healthcare Cost and Utilization Project Nationwide Readmissions Database (NRD), using unique patient linkage codes and International Classification of Diseases, Tenth Revision codes. Patient demographics, comorbidities, and outcomes were analyzed. Univariate logistic regression analyzed primary outcomes of 30- and 90-day readmission rates in weekday or weekend groups. Multivariate regression determined the impact of complications on readmission rates.Results: Compared to the weekday group (n = 125,590), the weekend group (n = 1,026) held a higher percentage of Medicare/Medicaid insurance, incurred higher costs, had longer length of stay, and fewer routine home discharge (all p < 0.001). There was no difference in comorbidity burden between weekend versus weekday admissions, as measured by the Elixhauser Comorbidity Index (p = 0.527). Weekend admissions had higher 30-day (4.30% vs. 7.60%, p < 0.001) and 90-day (7.80% vs. 16.10%, p < 0.001) readmission rates, even after adjusting for sex, age, insurance status, and comorbidities. All-cause complication rates were higher for weekend admissions (8.62% vs. 12.7%, p < 0.001), specifically deep vein thrombosis, infection, neurological conditions, and pulmonary embolism.Conclusion: Index weekend admission increases 30- and 90-day readmission rates after ECSF. In patients undergoing ECSF on weekends, postoperative care for patients at risk for specific complications will allow for improved outcomes and health care utilization.

Payor type is associated with increased rates of reoperation and health care utilization after rotator cuff repair: a national database study

BACKGROUND

Despite strong evidence supporting the efficacy of rotator cuff repair (RCR), previous literature has demonstrated that socioeconomic disparities exist among patients who undergo surgery. There is a paucity of literature examining whether payor type, including Medicare, Medicaid, and commercial insurance types, impacts early medical complications and rates of reoperation after RCR.

METHODS

Patients with Medicare, Medicaid, or commercial payor-type insurance who underwent primary open or arthroscopic RCR between 2010 and 2019 were identified using a large national database. Ninety-day incidence of medical complications, emergency department (ED) visit, and hospital readmission, as well as 1-year incidence of revision repair, revision to arthroplasty, and cost of care were evaluated. Propensity-score matching was used to control for patient demographic factors and comorbidities as covariates.

RESULTS

A total of 113,257 Medicare, 23,074 Medicaid, and 414,447 commercially insured patients were included for analysis. Medicaid insurance was associated with an increased 90-day risk of various medical complications, ED visit (odds ratio [OR]: 2.87; P < .001), and 1-year revision RCR (OR: 1.60; P < .001) compared with Medicare insurance. Medicaid insurance was also associated with an increased risk of various medical complications, ED visit (OR: 2.98; P < .001), and hospital readmission (OR: 1.56; P = .002), as well as 1-year risk of revision RCR (OR: 1.60; P < .001) and conversion to arthroplasty (OR: 1.4358; P < .001) compared with commercially insured patients. Medicaid insurance was associated with a decreased risk of conversion to arthroplasty compared with Medicare patients (OR: 0.6887; P < .001). Medicaid insurance was associated with higher 1-year cost of care compared with patients with both Medicare (P < .001) and commercial insurance (P < .001).

DISCUSSION

Medicaid insurance is associated with increased rates of medical complications, health care utilization, and reoperation after rotator cuff surgery, despite controlling for covariates. Medicaid insurance is also associated with a higher 1-year cost of care. Understanding the complex relationship between sociodemographic factors, such as insurance status, medical comorbidities, and outcomes, is necessary to ensure optimal health care access for all patients and to allow for appropriate risk stratification.

Is there variation in utilization of preoperative tests among patients undergoing total hip and knee replacement in the US, and does it affect outcomes? A population-based analysis

Study objective

To describe recent practice patterns of preoperative tests and to examine their association with 90-day all-cause readmissions and length of stay.

Design

Retrospective cohort study using the New York Statewide Planning and Research Cooperative System (SPARCS).

Setting

SPARCS from March 1, 2016, to July 1, 2017.

Participants

Adults undergoing Total Hip Replacement (THR) or Total Knee Replacement (TKR) had a preoperative screening outpatient visit within two months before their surgery.

Interventions

Electrocardiogram (EKG), chest X-ray, and seven preoperative laboratory tests (RBCs antibody screen, Prothrombin time (PT) and Thromboplastin time, Metabolic Panel, Complete Blood Count (CBC), Methicillin Resistance Staphylococcus Aureus (MRSA) Nasal DNA probe, Urinalysis, Urine culture) were identified.

Primary and secondary outcome measures

Regression analyses were utilized to determine the association between each preoperative test and two postoperative outcomes (90-day all-cause readmission and length of stay). Regression models adjusted for hospital-level random effects, patient demographics, insurance, hospital TKR, THR surgical volume, and comorbidities. Sensitivity analysis was conducted using the subset of patients with no comorbidities.

Results

Fifty-five thousand ninety-nine patients (60% Female, mean age 66.1+/− 9.8 SD) were included. The most common tests were metabolic panel (74.5%), CBC (66.8%), and RBC antibody screen (58.8%). The least common tests were MRSA Nasal DNA probe (13.0%), EKG (11.7%), urine culture (10.7%), and chest X-ray (7.9%). Carrying out MRSA testing, urine culture, and EKG was associated with a lower likelihood of 90-day all-cause readmissions. The length of hospital stay was not associated with carrying out any preoperative tests. Results were similar in the subset with no comorbidities.

Conclusions

Wide variation exists in preoperative tests before THR and TKR. We identified three preoperative tests that may play a role in reducing readmissions. Further investigation is needed to evaluate these findings using more granular clinical data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05945-y.

Incidence, predictors, and outcomes of early hospital readmissions after kidney transplantation: Systemic review and meta-analysis

BACKGROUND

Early hospital readmission (EHR) within 30 days after kidney transplantation is a significant quality indicator of transplant centers and patient care. This meta-analysis aims to evaluate the incidence, predictors, and outcomes of EHR after kidney transplantation.

METHODS

We comprehensively searched the databases, including PubMed, Cochrane CENTRAL, and Embase, from inception until December 2021 to identify studies that assessed incidence, risk factors, and outcome of EHR. The outcomes included death-censored graft failure and mortality. Data from each study were combined using the random effect to calculate the pooled incidence, mean difference (MD), odds ratio (OR), and hazard ratio (HR) with 95% confidence interval (CI).

RESULTS

A total of 17 studies were included. The pooled EHR incidence after kidney transplant was 24.4% (95% CI 21.7-27.3). Meta-analysis showed that recipient characteristics, including older recipient age (MD 2.05; 95% CI 0.90-3.20), Black race (OR 1.31; 95% CI 1.11, 1.55), diabetes (OR 1.32; 95% CI 1.22-1.43), and longer dialysis duration (MD 0.85; 95% CI 0.41, 1.29), donor characteristics, including older donor age (MD 2.02; 95% CI 0.93-3.11), and transplant characteristics, including delayed graft function (OR 1.75; 95% CI 1.42-2.16) and longer length of hospital stay during transplantation (MD 1.93; 95% CI 0.59-3.27), were significantly associated with the increased risk of EHR. EHR was significantly associated with the increased risk of death-censored graft failure (HR 1.70; 95% CI 1.43-2.02) and mortality (HR 1.46; 95% CI 1.27-1.67) within the first year after transplantation.

CONCLUSION

Almost one-fourth of kidney transplant recipients had EHR within 30 days after transplant, and they had worse post-transplant outcomes. Several risk factors for EHR were identified. This calls for future research to develop and implement for management strategies to reduce EHR in high-risk patients.

Do Multidisciplinary Spine Conferences Alter Management or Impact Outcome?

BACKGROUND

Multidisciplinary spine conferences (MSCs) are a strategy for discussing diagnostic and treatment aspects of patient care. Although they are becoming more common in hospitals, literature investigating how they impact patient care and outcomes is scarce. The aim of this study is to examine the impact of MSCs on surgical management and outcomes in elective spine surgical care.

METHODS

A systematic review of the literature was conducted to evaluate the impact of MSCs on patient management and outcomes. PubMed and Cochrane databases were searched using combinations and variations of search terms "Spine Conferences," "Multidisciplinary," and "Spine Team."

RESULTS

The literature search yielded 435 articles, of which 120 were selected for full-text review. Four articles (N = 529 patients) were included. Surgical plans were discussed in 211 patients. The decision was altered to conservative treatment in 70 patients (33.17%) and a different surgical strategy in 34 patients (16.11%). The differences were significant in 2 studies (P < 0.05). A 51% reduction in 30-day complications rates was observed when MSC was implemented in patients with adult complex scoliosis. Other spinal disorders showed a 30-day complication rate between 0% and 14% after MSC.

CONCLUSIONS

To our knowledge, this is the first systematic review of outcomes of MSCs in elective spine surgery and it confirms that MSCs impact management plan and outcomes. Consistent MSCs that include surgeons and nonsurgeons have the potential to enhance communication between specialists, standardize treatments, improve patient care, and encourage teamwork. More analysis is warranted to determine if patient outcomes are improved with these measures.

Prevention of Orthopedic Prosthetic Infections Using Evidence-Based Surgical Site Infection Care Bundles: A Narrative Review

Background: The number of primary/revision total joint replacements (TJR) are expected to increase substantially with an aging population and increasing prevalence of comorbid conditions. The 30-day re-admission rate, in all orthopedic specialties, is 5.4% (range, 4.8%-6.0%). A recent publication has documented that the surgical site infection (SSI) infection rate associated with revision total knee (rTKR, 15.6%) and revision total hip (rTHR, 8.6%) arthroplasties are four to seven times the rate of the primary procedures (2.1%-2.2%). These orthopedic infections prolong hospital stays, double re-admissions, and increase healthcare costs by a factor of 300%. Methods: A search of PubMed/MEDLINE, EMBASE and the Cochrane Library publications, which reported the infection risk after TKR and THR, was undertaken (January 1, 1995 to December 31, 2021). The search also included documentation of evidence-based practices that lead to improved post-operative outcomes. Results: The evidence-based approach to reducing the risk of SSI was grouped into pre-operative, peri-operative, and post-operative periods. Surgical care bundles have existed within other surgical disciplines for more than 20 years, although their use is relatively new in peri-operative orthopedic surgical care. Pre-admission chlorhexidine gluconate (CHG) showers/cleansing, staphylococcal decolonization, maintenance of normothermia, wound irrigation, antimicrobial suture wound closure, and post-operative wound care has been shown to improve clinical outcome in randomized controlled studies and meta-analyses. Conclusions: Evidence-based infection prevention care bundles have improved clinical outcomes in all surgical disciplines. The significant post-operative morbidity, mortality, and healthcare cost, associated with SSIs after TJR can be reduced by introduction of evidence-based pre-operative, intra-operative, and post-operative interventions.

Operative Time Less Than 1.5 Hours, Male Sex, Dependent Functional Status, Presence of Dyspnea, and Reoperations Within 30 days Are Independent Risk Factors for Readmission After ACLR

Purpose

The purposes of this study are to use a large, patient-centered database to describe the 30-day readmission rate and to identify predictive risk factors for readmission after elective isolated ACLR.

Methods

The National Surgical Quality Improvement Program Database was retrospectively queried for isolated ACLR procedures between 2011 and 2017. Current Procedural Terminology (CPT) codes were used to identify isolated ACLR patients. Those undergoing additional procedures such as meniscectomy or multi-ligamentous reconstruction were excluded. Readmissions were analyzed against demographic variables with bivariate analysis. Multivariate logistic regression was used to find independent risk factors for 30-day readmissions after ACLR.

Results

A total of 11,060 patients (37.2% female) were included with an average age of 32.2 ± 10.6 years and mean body mass index (BMI) of 27.9 ± 6.5 kg/m² (29.2% were >30). The overall readmission rate was 0.59%. The most reported reason for readmission was infection 0.22 (24 out of 11,060). The following variables were associated with significantly higher readmission rates: male sex (P = .001), history of severe chronic obstructive pulmonary disease (COPD) (P = .025), cardiac comorbidity (P = .034), operative time >1.5 hours (P <.001), partially dependent functional health status (P = .002), high preoperative creatinine (P = .009), normal preoperative albumin (P = .020), hypertension (P = .034), and reoperations (P < .001). Operative time >1.5 hours, male sex, dependent functional status, the presence of dyspnea, and undergoing a reoperation were identified as independent risk factors for 30-day readmissions (P < .05 for all).

Conclusions

Isolated ACLR is associated with low 30-day readmission rates. Operative time >1.5 hours, male sex, dependent functional status, the presence of dyspnea, and 30-day reoperations are independent risk factors for readmission that should be considered in patient selection and addressed with preoperative counseling.

Level of Evidence

Level III, retrospective cohort study.

Profound Impact of Insurance Payor and Socioeconomic Status in Total Hip Arthroplasty Outcomes: Results From a High Volume Tertiary Care Center

BACKGROUND

Dual eligible Medicare/Medicaid patients undergoing total hip arthroplasty (THA) have worse outcomes compared to other insurance payors. Prior literature fails to control for the heterogeneity of care provided amongst a large cohort of hospitals and surgeons as well as differences in patient populations treated. This study compares dual eligible THA patients and Medicaid and Medicare only THA patients at a single high volume tertiary center.

METHODS

We retrospectively reviewed patients who underwent THA for aseptic osteoarthritis of the hip over a three-year period with either Medicaid or Medicare insurance. 3,329 THA patients were included, of which 439 were Medicaid payor, 182 were dual eligible, and 2,708 were Medicare payor. Groups were compared using appropriate tests for direct comparisons and regression analysis.

RESULTS

Dual eligible patients were less likely to be white and married, and were more likely to be current smokers and have COPD, liver disease, renal disease, and human immunodeficiency virus (HIV) compared to Medicare patients. These patients also had a lower age-adjusted Charleson Comorbidity Index when compared to Medicare patients (2.4 vs 3.4, P < .001). When controlling for smoking status, age, BMI and major medical comorbidities, dual eligible and Medicaid patients had increased length of stay (LOS) (0.58, 0.66 days, P < .001), higher risk of discharge to subacute rehabilitation (RR 1.97, 3.19, P < .001), and dual eligible patients more often returned to the ED within 90 days (RR 2.74, P < .001) compared to Medicare patients.

CONCLUSION

This study supports the implementation of socioeconomic risk stratification efforts to properly evaluate value-based healthcare metrics in total hip arthroplasty patients.

Does Dual-Eligible Medicare/Medicaid Insurance Status as a Surrogate for Socioeconomic Status Compromise Total Knee Arthroplasty Outcomes?

BACKGROUND

Medicare/Medicaid dual-eligible patients who undergo primary total knee arthroplasty (TKA) demonstrate poor outcomes when compared to patients with other payers. We compare Medicare/Medicaid dual-eligible patients vs Medicare and Medicaid only patients at a single hospital center.

METHODS

All patients who underwent TKA for aseptic arthritis between August 9, 2016 and December 30, 2020 with either Medicare or Medicaid insurance were retrospectively reviewed. 4599 consecutive TKA (3749 Medicare, 286 Medicare/Medicaid dual eligibility, and 564 Medicaid) were included. Groups were compared using appropriate tests for direct comparisons and regression analysis.

RESULTS

Patients with dual eligibility and Medicaid insurance were less likely to be white and married, more likely to be female and current smokers, and more likely to have COPD, mild liver disease, diabetes mellitus, malignancy, and HIV/AIDS, but had a lower age-adjusted Charleson Comorbidity Index when compared to Medicare patients. When controlling for smoking status and medical comorbidities, patients with dual eligibility and Medicaid insurance stayed in the hospital 0.64 and 0.39 additional days (P < .001), respectively, were more likely to be discharged to subacute rehab (RR 2.01, 1.49, P < .001) and acute rehab (RR 2.22, 2.46, P = .007, < .001), and were 2.14 and 1.73 times more likely to return to the ED within 90 days (P < .001) compared to Medicare patients.

CONCLUSION

Value-based healthcare may disincentivize treating patients with low socioeconomic status, represented by Medicaid and dual-eligible insurance status, by their association with increased postoperative healthcare utilization, and less risky patients may be prioritized.

Decreased Implant Survival is Associated With Younger Patients Undergoing Total Knee Arthroplasty

Background: Younger patients are undergoing total knee arthroplasty (TKA) at increasing rates and may face multiple revisions during their lifetimes due to mechanical complications or infections. Questions/Purposes: We sought to compare the early complication rates and revision-free implant-survival rates across age groups of patients undergoing TKA, with particular focus on implant survival in younger patients. Methods: We conducted a retrospective analysis of data taken from a national insurance database on patients who underwent primary TKA from 2007 to 2015. Kaplan-Meier curve survival analysis and log rank test were performed to evaluate revision rates in 7 age groups (younger than 40, 40-49, 50-59, 60-69, 70-79, 80-89, and 90 or more years of age). Complication rates were compared to rates in the age 60 to 79 years age groups using multiple logistic regression, controlling for baseline demographics and comorbidities. Results: There were 114,698 patients included in the analysis. Patients in the younger than 40 years, 40 to 49 years, and 50 to 59 years age groups had increased rates of early mechanical complications; 90-day readmission rates were significantly higher in those age groups as well. Revision-free implant survival at 5 years was significantly worse in patients younger than 60 years of age, particularly those less than 40 years, who had a 77% revision-free implant-survival rate at 5 years. Conclusions: Younger patients had a higher risk of early revision after TKA, as well as an increased rate of mechanical complications and readmissions at 90 days. These outcomes suggest more study is needed to better understand these discrepancies and to better guide preoperative counseling for young patients considering TKA.

The Impact of Social Determinants of Health on 30 and 90-Day Readmission Rates After Spine Surgery

BACKGROUND

Since its 2012 inception, the U.S. Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program (HRRP) has espoused cost-effective health-care delivery by financially penalizing hospitals with excessive 30-day readmission rates. In this study, we hypothesized that socioeconomic factors impact readmission rates of patients undergoing spine surgery.

METHODS

In this study, 2,830 patients who underwent a spine surgical procedure between 2012 and 2018 were identified retrospectively from our institutional database, with readmission (postoperative day [POD] 0 to 30 and POD 31 to 90) as the outcome of interest. Patients were linked to U.S. Census Tracts and ZIP codes using the Geographic Information Systems (ArcGIS) mapping program. Social determinants of health (SDOH) were obtained from publicly available databases. Patient income was estimated at the Public Use Microdata Area level based on U.S. Census Bureau American Community Survey data. Univariate and multivariable stepwise regression analyses were conducted. Significance was defined as p < 0.05, with Bonferroni corrections as appropriate.

RESULTS

Race had a significant effect on readmission only among patients whose estimated incomes were <$31,650 (χ2 = 13.4, p < 0.001). Based on a multivariable stepwise regression, patients with estimated incomes of <$31,000 experienced greater odds of readmission by POD 30 compared with patients with incomes of >$62,000; the odds ratio (OR) was 11.06 (95% confidence interval [CI], 6.35 to 15.57). There were higher odds of 30-day readmission for patients living in neighborhoods with higher diabetes prevalence (OR, 3.02 [95% CI, 1.60 to 5.49]) and patients living in neighborhoods with limited access to primary care providers (OR, 1.39 [95% CI, 1.10 to 1.70]). Lastly, each decile increase in the Area Deprivation Index of a patient's Census Tract was associated with higher odds of 30-day readmission (OR, 1.40 [95% CI, 1.30 to 1.51]).

CONCLUSIONS

Socioeconomically disadvantaged patients and patients from areas of high social deprivation have a higher risk of readmission following a spine surgical procedure.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of Surgeon Experience on Outcomes of Anterior Cervical Discectomy and Fusion

INTRODUCTION

The relationship between surgeon experience and cervical fusion outcomes has yet to be assessed. We investigate perioperative characteristics, patient-reported outcomes (PROMs), and minimal clinically important difference (MCID) achievement after anterior cervical diskectomy and fusion (ACDF) by the volume of cases done throughout an orthopaedic spine surgeon's career.

METHODS

ACDF procedures between 2005 and 2020 were identified. Group I included the first half of ACDF cases (#1-#321). PROMs were introduced in the second half of the ACDF cases; thus, the next 322 cases were subdivided to compare PROM and MCID between subgroups (cases #322 to #483 = group II and #484 to #645 = group III). PROMs, including VAS back/leg, Oswestry Disability Index (ODI), Short Form-12 Physical Composite Score, and PROMIS-PF, were collected preoperatively/postoperatively. Demographics, perioperative variables, mean PROMs, and MCID achievement were compared between groups and subgroups using the Student t-test and chi-square. Logistic regression evaluated MCID achievement using the established threshold values.

RESULTS

A total of 642 patients were included (320 in group I, 161 in group II, and 161 in group III). The latter cases had significantly decreased surgical time, blood loss, and postoperative length of stay in comparison of groups and subgroups (P ≤ 0.002, all). CT-confirmed 1-year arthrodesis rates were increased among the latter cases (P = 0.045). Group II had significantly higher arthrodesis rates than group III (P = 0.039). The postoperative complication rates were lower in the latter cases (P < 0.001, all), whereas subgroup analysis revealed lower incidence of urinary retention and other complications in group III (P ≤ 0.031, all). Mean PROMs were significantly inferior in group II versus group III for VAS neck at 6 months (P = 0.030), Neck Disability Index at 6 months preoperatively (P ≤ 0.022, both), Short Form-12 Physical Composite Score at 12 weeks/2 years (P ≤ 0.047, both), and PROMIS-PF at 12 weeks/6 months (P ≤ 0.036, both). The MCID attainment rates were higher among group III for VAS neck/Neck Disability Index at 2 years (P ≤ 0.005) and overall achievement across all PROMs (P ≤ 0.015, all).

DISCUSSION

Increased ACDF case volume may lead to markedly decreased surgical time, blood loss, and length of postoperative stay as well as improved clinical outcomes in pain, disability, and physical function.

Obesity, Comorbidities, and the Associated Risk among Patients Who Underwent Total Knee Arthroplasty in Alberta

Obesity, a common risk factor for osteoarthritis (OA), accelerates joint deterioration resulting in the need for early total knee arthroplasty (TKA). The role of obesity in the management of OA remains a controversial topic. In this study, we examined whether obesity along with other comorbidities is associated with peri/postoperative complications in patients who underwent primary unilateral TKA in Alberta, Canada. A retrospective secondary analysis was performed on data extracted from data repository of patients (n = 15,151) who underwent TKA between 2012 and 2016. The sample was divided into five groups based on body mass index (BMI) classification developed by the World Health Organization. The associations between dependent variable (presence or absence of a complication or comorbidity) with the independent variables (year of surgery, age, sex, length of surgery, and BMI groups) were examined using binomial logistic regression. Results showed that obese classes I, II, and III, irrespective of other covariates, were more likely to have diabetes and pulmonary embolism (p < 0.001) compared with the normal BMI group. Patients with obese class III compared with the patients in normal BMI group were more likely to have deep wound infection (p = 0.04). Patients with comorbidities were more likely to have a blood transfusion, infection, pulmonary embolism, and readmission. Patients in higher BMI groups or with comorbidities were more likely to experience peri/postoperative complications following TKA, though the level of risk depends on the severity of obesity. These findings may be used by health care providers to educate patients in higher BMI groups about the risks of TKA and optimize comorbidities prior to the surgery.

Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care

BACKGROUND

There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care.

OBJECTIVE

We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels.

METHODS

Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics.

PRINCIPAL FINDINGS

Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers.

CONCLUSIONS

Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.

Readmissions after elective orthopedic surgery in a comprehensive co-management care system-a retrospective analysis

Background

No surgical intervention is without risk. Readmissions and reoperations after elective orthopedic surgery are common and are also stressful for the patient. It has been shown that a comprehensive ortho-medical co-management model decreases readmission rates in older patients suffering from hip fracture; but it is still unclear if this also applies to elective orthopedic surgery. The aim of the current study was to determine the proportion of unplanned readmissions or returns to operating room (for any reason) across a broad elective orthopedic population within 90 days after elective surgery. All cases took place in a tertiary care center using co-management care and were also assessed for risk factors leading to readmission or unplanned return to operating room (UROR).

Methods

In this observational study, 1295 patients undergoing elective orthopedic surgery between 2015 and 2017 at a tertiary care center in Switzerland were investigated. The proportion of reoperations and readmissions within 90 days was measured, and possible risk factors for reoperation or readmission were identified using logistic regression.

Results

In our cohort, 3.2% (42 of 1295 patients) had an UROR or readmission. Sixteen patients were readmitted without requiring further surgery—nine of which due to medical and seven to surgical reasons. Patient-related factors associated with UROR and readmission were older age (67 vs. 60 years; p = 0.014), and American Society of Anesthesiologists physical status (ASA PS) score ≥ 3 (43% vs. 18%; p < 0.001). Surgery-related factors were: implantation of foreign material (62% vs. 33%; p < 0.001), duration of operation (76 min. vs. 60 min; p < 0.001), and spine surgery (57% vs. 17%; p < 0.001). Notably, only spine surgery was also found to be independent risk factor.

Conclusion

Rates of UROR during initial hospitalization and readmission were lower in the current study than described in the literature. However, several comorbidities and surgery-related risk factors were found to be associated with these events. Although no surgery is without risk, known threats should be reduced and every effort undertaken to minimize complications in high-risk populations. Further prospective controlled research is needed to investigate the potential benefits of a co-management model in elective orthopedic surgery.

30-Day Outcomes for Total Ankle Arthroplasty in Patients With Anemia

BACKGROUND

While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty.

METHODS

A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia.

RESULTS

Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P < .008), increased rate of 30-day readmission (3.5% vs 1.1%, P = .036), increased 30-day reoperation (2.6% vs 0.4%, P = .007), extended length of stay (64% vs 49.9%, P = .004), wound complication (1.75% vs 0.11%, P = .002), and surgical site infection (2.6% vs 0.6%, P = .017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P = .023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P = .033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P = .066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P = .71).

CONCLUSION

This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Readmissions after ventricular shunting in pediatric patients with hydrocephalus: a Nationwide Readmissions Database analysis

OBJECTIVE

Cerebrospinal fluid diversion via ventricular shunting is a common surgical treatment for hydrocephalus in the pediatric population. No longitudinal follow-up data for a multistate population-based cohort of pediatric patients undergoing ventricular shunting in the United States have been published. In the current review of a nationwide population-based data set, the authors aimed to assess rates of shunt failure and hospital readmission in pediatric patients undergoing new ventricular shunt placement. They also review patient- and hospital-level factors associated with shunt failure and readmission.

METHODS

Included in this study was a population-based sample of pediatric patients with hydrocephalus who, in 2010-2014, had undergone new ventricular shunt placement and had sufficient follow-up, as recorded in the Nationwide Readmissions Database. The authors analyzed the rate of revision within 6 months, readmission rates at 30 and 90 days, and potential factors associated with shunt failure including patient- and hospital-level variables and type of hydrocephalus.

RESULTS

A total of 3520 pediatric patients had undergone initial ventriculoperitoneal shunt placement for hydrocephalus at an index admission. Twenty percent of these patients underwent shunt revision within 6 months. The median time to revision was 44.5 days. Eighteen percent of the patients were readmitted within 30 days and 31% were readmitted within 90 days. Different-hospital readmissions were rare, occurring in ≤ 6% of readmissions. Increased hospital volume was not protective against readmission or shunt revision. Patients with grade 3 or 4 intraventricular hemorrhage were more likely to have shunt malfunctions. Patients who had private insurance and who were treated at a large hospital were less likely to be readmitted.

CONCLUSIONS

In a nationwide, population-based database with longitudinal follow-up, shunt failure and readmission were common. Although patient and hospital factors were associated with readmission and shunt failure, system-wide phenomena such as insufficient centralization of care and fragmentation of care were not observed. Efforts to reduce readmissions in pediatric patients undergoing ventricular shunt procedures should focus on coordinating care in patients with complex neurological diseases and on reducing healthcare disparities associated with readmission.

Insulin Dependence Increases the Risk of 30-Day Postoperative Complications Following Ankle Fracture Surgery in Patients With Diabetes Mellitus

Patients with diabetes mellitus that undergo ankle fracture surgery have higher rates of postoperative complications compared to patients without diabetes mellitus. We evaluated the rate of complications in insulin-dependent diabetes mellitus patients, non-insulin-dependent diabetes mellitus patients, and patients without diabetes in the 30-day postoperative period following ankle fracture surgery. We also analyzed hospital length of stay, unplanned readmission, unplanned reoperation, and death. Patients who underwent operative management for ankle fractures between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database using Current Procedural Terminology codes. Multiple logistic regression was implemented. Adjusted odds ratios were calculated along with the 95% confidence interval. A total of 19,547 patients undergoing ankle surgery were identified from 2012 to 2016. Of these patients, 989 (5.06%) had insulin-dependent diabetes mellitus, 1256 (6.43%) had noninsulin-dependent diabetes mellitus, and 17,302 (88.51%) did not have diabetes mellitus. Compared to patients without diabetes, patients with insulin-dependent diabetes mellitus had significantly greater adjusted odds of superficial surgical site infections, deep surgical site infections, osteomyelitis, wound dehiscence, pneumonia, unplanned intubation, mechanical ventilation, urinary tract infection, cardiac arrest, bleeding requiring transfusion, sepsis, hospital length of stay, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery. We demonstrate that insulin-dependent diabetes mellitus is a strong predictor of 30-day postoperative complications, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery.

Age Is Just a Number: Patient Age Does Not Affect Outcome Following Surgery for Osteoporotic Vertebral Compression Fractures

STUDY DESIGN

Retrospective study.

OBJECTIVE

Multiple studies have shown that osteoporotic patients are at an increased risk for medical and surgical complications, making optimal management of these patients challenging. The purpose of this study was to determine the relationship between patient age and the likelihood of surgical complications, mortality, and 30-day readmission rates following surgery for osteoporotic vertebral compression fractures (OVCFs).

METHODS

A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients who met inclusion criteria. A multivariate logistic regression analysis was conducted to calculate odds ratios (OR), with corresponding P values and 95% confidence intervals, of the relationship between age (treated as a continuous variable) and perioperative mortality, surgical complications, and 30-day readmission rates.

RESULTS

Younger patients were statistically more likely to endure a minor (OR = 0.98; P = .002) or major complication (OR = 0.97; P = .009). The older a patient was, on the other hand, the higher the likelihood that patient would be readmitted within 30 days of surgery (OR =1.02; P = .004). Mortality within the 30-day perioperative period was not statistically correlated with age.

CONCLUSIONS

The impact of age on adverse outcomes following surgery for OVCF is mixed. While younger patients are more likely to endure complications, older patients are more likely to be readmitted within 30 days following surgery. Patient age showed no correlation with mortality rates. In the setting of surgical treatment for an OVCF, a patient's age can help determine the risk of complications and the rate of readmission following intervention.

Removal of instrumentation for postoperative spine infection: systematic review

OBJECTIVE

Currently, no consensus exists as to whether patients who develop infection of the surgical site after undergoing instrumented fusion should have their implants removed at the time of wound debridement. Instrumentation removal may eliminate a potential infection nidus, but removal may also destabilize the patient's spine. The authors sought to summarize the existing evidence by systematically reviewing published studies that compare outcomes between patients undergoing wound washout and instrumentation removal with outcomes of patients undergoing wound washout alone. The primary objectives were to determine 1) whether instrumentation removal from an infected wound facilitates infection clearance and lowers morbidity, and 2) whether the chronicity of the underlying infection affects the decision to remove instrumentation.

METHODS

PRISMA guidelines were used to review the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify studies that compared patients with implants removed and patients with implants retained. Outcomes of interest included mortality, rate of repeat wound washout, and loss of correction.

RESULTS

Fifteen articles were included. Of 878 patients examined in these studies, 292 (33%) had instrumentation removed. Patient populations were highly heterogeneous, and outcome data were limited. Available data suggested that rates of reoperation, pseudarthrosis, and death were higher in patients who underwent instrumentation removal at the time of initial washout. Three studies recommended that instrumentation be uniformly removed at the time of wound washout. Five studies favored retaining the original instrumentation. Six studies favored retention in early infections but removal in late infections.

CONCLUSIONS

The data on this topic remain heterogeneous and low in quality. Retention may be preferred in the setting of early infection, when the risk of underlying spine instability is still high and the risk of mature biofilm formation on the implants is low. However, late infections likely favor instrumentation removal. Higher-quality evidence from large, multicenter, prospective studies is needed to reach generalizable conclusions capable of guiding clinical practice.

2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial

AIMS

The purpose is to determine the non-inferiority of a smartphone-based exercise educational care management system after primary knee arthroplasty compared with a traditional in-person physiotherapy rehabilitation model.

METHODS

A multicentre prospective randomized controlled trial was conducted evaluating the use of a smartphone-based care management system for primary total knee arthroplasty (TKA) and partial knee arthroplasty (PKA). Patients in the control group (n = 244) received the respective institution's standard of care with formal physiotherapy. The treatment group (n = 208) were provided a smartwatch and smartphone application. Early outcomes assessed included 90-day knee range of movement, EuroQoL five-dimension five-level score, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score, 30-day single leg stance (SLS) time, Time up and Go (TUG) time, and need for manipulation under anaesthesia (MUA).

RESULTS

Overall, 90-day mean flexion was not significantly different between the control (121° (SD 11.7°)) and treatment groups (121^o; p = 0.559); 90-day mean SLS was 22.7 seconds (SD 9.8) in controls and 24.3 seconds (SD 20.8) in treatment (p = 0.519); 90-day mean TUG times were 10.1 seconds (SD 4.8) in control and 9.3 seconds (SD 3.3) in treatment (p = 0.139). Mean KOOS JR scores were significantly different between control group (73.6 (SD 13.4)) and treatment group (70.4 (SD 12.6); p = 0.026). MUAs were performed in nine (3.7%) patients in the control group and four (1.9%) in the treatment group (p = 0.398). Physiotherapy was performed by 230 (94.4%) of control group and 123 (59.3%) of treatment group (p < 0.001). There were no significant differences between groups in postoperative urgent care visits, or readmissions within 90 days, with significantly fewer emergency department visits in the treatment group (16 (8.2%) vs five (2.5%), p = 0.014).

CONCLUSION

The use of the smartwatch/smartphone care platform demonstrated non-inferiority of clinically significant outcomes to traditional care models, while requiring significantly less postoperative physiotherapy and fewer emergency department visits. This platform could aid in decreasing postoperative costs, while improving patient engagement and communication with the healthcare team. Cite this article: Bone Joint J 2021;103-B(6 Supple A):3-12.

Incidence and burden of Staphylococcus aureus infection after orthopedic surgeries

OBJECTIVE

To assess the 180-day incidence of Staphylococcus aureus infections following orthopedic surgeries using microbiology cultures.

DESIGN

Retrospective observational epidemiology study.

SETTING

National administrative hospital database.

PATIENTS

Adult patients with an elective admission undergoing orthopedic surgeries in the inpatient and hospital-based outpatient settings discharged between July 1, 2010, and June 30, 2015.

METHODS

Patients were identified from 181 hospitals reporting microbiology results to the Premier Healthcare Database. Orthopedic surgeries were defined using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure and current procedural terminology (CPT) codes. Microbiology cultures and ICD-9/10 diagnosis codes identified surgical site infections (SSIs), bloodstream infections (BSIs), and other infections associated postoperatively (eg, respiratory and urinary tract infections).

RESULTS

Among 359,268 inpatient orthopedic surgical encounters, the S. aureus infection incidence was 1.13%: SSI, 0.68%; BSI, 0.28%; and other types, 0.17%. Among 292,011 outpatient encounters, the S. aureus incidence was 0.78%: SSI, 0.55%; BSI, 0.12%; and other types, 0.11%. Methicillin-resistant S. aureus (MRSA) infections accounted for 46% and 44% in the respective settings. Plastic/hand-limb reattachment and amputation had the highest overall S. aureus incidence in both settings. S. aureus was the most commonly isolated microorganism among culture-confirmed SSIs (48.0%) and BSIs (35.0%), followed by other Enterobacteriaceae (14.0%) for SSIs and Escherichia spp (12.5%) for BSIs.

CONCLUSIONS

These findings suggest that S. aureus infections continue to be an important contributor to the burden of postoperative infections after inpatient and outpatient orthopedic procedures.

Quantifying the Impact of Comorbidities on Outcomes Following Surgery for Osteoporotic Vertebral Compression Fractures

Introduction Studies have shown that osteoporotic patients are more likely to have medical or surgical complications postoperatively. In this study, we determine the predictive value of various comorbidities on the likelihood of postoperative complications, mortality, and 30-day readmission following cement augmentation for osteoporotic vertebral compression fractures (OVCFs).

Materials and Methods A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients who met inclusion criteria. A multivariate logistic regression analysis was utilized to determine the relationship between various comorbidities and perioperative mortality, postoperative complications, and 30-day readmission rates.

Results A history of cerebrovascular accident (CVA), coagulopathy, diminished preoperative functional status, and/or an American Society of Anesthesiologists (ASA) class > 2 were statistical predictors of postoperative complications. CVA generated the highest odds ratio among these comorbidities (OR = 5.36, p = 0.02 for minor complications; OR = 4.60 p = 0.05 for major complications). Among the 15 comorbidities considered, steroid use (OR =1.81; p = 0.03) and an ASA class > 2 (OR = 14.65; p = 0.01) were the only ones that were correlated with mortality; an ASA class > 2 had a particularly strong effect on the likelihood of mortality (OR = 14.65). Chronic obstructive pulmonary disorder (COPD), obesity, significant weight loss, and an ASA class > 2 were correlated with 30-day readmissions. Congestive heart failure (CHF), diabetes, dialysis, hypertension, or smoking was not correlated with adverse postoperative outcomes.

Conclusion Of the 15 comorbidities considered in this study, four were statistically associated with increased rates of postoperative complications, two were associated with increased mortality, and four were associated with increased rates of readmission at 30 days. The presence of CHF, diabetes mellitus (DM), hypertension, ascites, renal failure, or smoking were not associated with the adverse outcomes studied.

Level of Evidence III.

Comparing Plastic Surgeon Versus Orthopedic Surgeon Outcomes Following Distal Upper Extremity Amputations: A Study of the National Surgical Quality Improvement Program (NSQIP) Database

BACKGROUND

Both plastic and orthopedic surgeons manage care for urgent/emergent hand conditions. It is unclear if surgeon specialty affects patient outcomes of these cases. The purpose of this study was to evaluate differences in 30-day perioperative outcomes between plastic and orthopedic surgeons following distal upper extremity amputations.

METHODS

Patients who underwent distal upper extremity amputations between 2005 and 2016 were identified within the National Surgical Quality Improvement Program (NSQIP) database using Current Procedural Terminology (CPT) codes. Differences in operative procedures, patient demographics, patient comorbidities, and 30-day perioperative complications were compared between orthopedic and plastic surgeons by univariate analysis. A Bonferroni correction was applied to account for multiple comparisons of complications.

RESULTS

A total of 1583 cases met inclusion criteria. Orthopedic surgeons performed 981 cases (62.0%) and plastic surgeons performed 602 cases (38.0%). Finger amputations comprised the majority of procedures for both orthopedic and plastic surgeons (95.5% and 94.4%, respectively). Orthopedic surgeons had a lower operative time (41.7 ± 36.2 minutes vs 47.1 ± 40.9 minutes, P = .008). There were no differences in proportion of emergency surgery, inpatients, or wound class. There were no differences in age, gender, or body mass index. The most common indications for amputation were trauma, gangrene, and osteomyelitis. There were no differences between surgical specialties in 18 30-day perioperative complications assessed, including death, reoperation, surgical site infection, or wound dehiscence.

CONCLUSIONS

Plastic and orthopedic surgeons achieved equivalent outcomes comparing 30-day perioperative complications following upper extremity amputations. These results support that both orthopedic and plastic surgeons provide similar quality distal upper extremity amputation care.

Males Have Higher Rates of Peri-operative Mortality Following Surgery for Osteoporotic Vertebral Compression Fracture

In this study, we evaluated the association between sex and the incidence of postoperative mortality in the peri-operative period following surgical intervention for OVCF. We found no statistical association between surgical complications and patient sex. However, males exhibited higher rates of mortality and 30-day readmissions relative to females.

INTRODUCTION

Osteoporotic vertebral compression fractures (OVCF) contribute substantially to the financial burden of the US healthcare system. As the size of the elderly population grows, the number of fractures attributed to osteoporosis is expected to increase. Studies have shown that osteoporotic patients are at an increased risk for medical and surgical complications. The purpose of this study was to evaluate the association between sex and the incidence of postoperative mortality in the peri-operative period following surgical intervention for OVCF.

METHODS

A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients. Patients were grouped as male or female. Mortality within 30 days of surgery due to any cause, incidence of surgical complications, and 30-day readmission rates following surgery were tabulated. A multivariate logistic regression analysis was conducted to calculate odds ratios (OR) with corresponding p values and 95% confidence intervals.

RESULTS

In total, 1979 patients met inclusion and exclusion criteria. Mortality within the 30 days following surgery for OVCF was statistically greater in men than in women (OR = 1.58; p = 0.050). The 30-day readmission rate was also statistically higher in men (OR = 1.41; p = 0.017). Neither minor (OR = 0.90; p = 0.560) nor major (OR = 1.14; p = 0.569) complications were statistically correlated with sex. On average, men underwent surgery for OVCF at a younger age than women.

CONCLUSIONS

Male patients undergoing surgery for OVCF have higher rates of peri-operative mortality and 30-day readmissions following surgery. Sex was not found to be associated with postoperative complications.

LEVEL OF EVIDENCE

III.

Increasing severity of anemia is associated with poorer 30-day outcomes for total shoulder arthroplasty

Background

Total shoulder arthroplasty (TSA) has increased in utilization over the past several decades. Anemia is a common preoperative condition among patients undergoing TSA and has been associated with poorer outcomes in other surgical procedures. To the best of our knowledge, no study has analyzed the association between anemia severity and TSA outcomes. Therefore, the purpose of this study is to determine the effects that increasing severity of anemia may have on the postoperative outcomes in patients receiving primary TSA.

Methods

A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from the years 2015 to 2018. Current Procedure Terminology code 23472 was used to identify all primary TSA procedures recorded during this time frame. Patients with greater than 38% preoperative hematocrit (HCT) were classified as having normal HCT levels. Patients with HCT values between 33% and 38% were classified as having mild anemia. All patients with less than 33% HCT were classified as having moderate/severe anemia. Patient demographic information, preoperative risk factors, and postoperative outcomes were compared among the 3 cohorts. A multivariate logistic regression including demographic factors and comorbidities was performed to determine whether increasing severity of anemia is independently associated with poorer postoperative outcomes.

Results

Of the 15,185 patients included in this study, 11,404 had normal HCT levels, 2962 patients were mildly anemic, and 819 patients had moderate to severe anemia. With increasing severity of anemia, there was an increased average hospital length of stay (1.6 vs. 2.1 vs. 3.0 days, P < .001), rate of readmissions (2.3% vs. 4.8% vs. 7.0%, P < .001), and rate of all reoperations (1.1% vs. 1.8% vs. 3.1%, P < .001). There was a statistically significant increase in both minor (1.9% vs. 2.7% vs. 4.4%, P < .001) and major (1.2% vs. 2.4% vs. 4.3%, P < .001) postoperative complication rates as well. Multivariate analysis identified anemia as an independent predictor of readmissions, reoperations, minor complications, and major complications.

Conclusion

We found increasing severity of anemia to be associated with progressively worse 30-day postoperative outcomes. This is consistent with the outcomes found for increasing severity of anemia in patients receiving other total joint procedures. Using preoperative HCT levels may be a useful tool for predicting the risk of postoperative complications in patients undergoing TSA. This information could be used to further optimize patient selection for primary TSA.

Serious adverse events and 30-day hospital readmission rate following elective total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Elective total knee arthroplasty (TKA) is a common surgery which has evolved rapidly. However, there are no recent large systematic reviews of serious adverse event (SAE) rate and 30-day readmission rate (30-dRR) or an indication of whether surgical methods have improved.

METHODS

To obtain a pooled estimate of SAE rate and 30-dRR following TKA, we searched Medline, Web of Science, Cochrane Library, and Google Scholar databases. Data were extracted by two authors following PRISMA guidelines. Eligibility criteria were defined prior to a comprehensive search. Studies were eligible if they were published in 2007 or later, described sequelae of TKA with patient N > 1000, and the SAE or 30-dRR rate could be calculated. SAEs included return to operating room, death or coma, venous thromboembolism (VTE), deep infection or sepsis, myocardial infarction, heart failure or cardiac arrest, stroke or cerebrovascular accident, or pneumonia.

RESULTS

Of 248 references reviewed, 28 are included, involving 10,153,503 patients; this includes 9,483,387 patients with primary TKA (pTKA), and 670,116 patients with revision TKA (rTKA). For pTKA, the SAE rate was 5.7% (95% CI 4.4-7.2%, I2 = 100%), and the 30-dRR was 4.8% (95% CI 4.3-5.4%, I2 = 100%). For rTKA, the SAE rate was 8.5% (95% CI 8.3-8.7%, I2 = 77%), while the 30-dRR was 7.2% (95% CI 6.4-8.0%, I2 = 81%). Odds of 30-dRR following pTKA were about half that of rTKA (OR 0.57, 95% CI 0.53-0.62%, p < 0.001, I2 = 45%). Of patients who received pTKA, the commonest SAEs were VTE (1.22%; 95% CI 0.83-1.70%) and genitourinary complications including renal insufficiency or renal failure (1.22%; 95% CI 0.83-1.67%). There has been significant improvement in SAE rate and 30-dRR since 2010 (χ2 test < 0.001).

CONCLUSIONS

TKA procedures have a relatively low complication rate, and there has been a significant improvement in SAE rate and 30-dRR over the past decade.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients

IMPORTANCE

The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown.

OBJECTIVE

To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs.

MAIN OUTCOME MEASURES

Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident.

RESULTS

The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities.

CONCLUSIONS

The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients

OBJECTIVE

Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization?

METHODS

We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010-September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed.

RESULTS

The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14-1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants.

CONCLUSIONS

Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.

K-Means Clustering to Elucidate Vulnerable Subpopulations Among Medicare Patients Undergoing Total Joint Arthroplasty

BACKGROUND

The role of preoperative laboratory values for risk stratification following joint arthroplasty is currently ambiguous. In order to improve upon existing risk stratification within joint arthroplasty, this study sought to define novel phenotypes of total hip or total knee arthroplasty patients based entirely on preoperative laboratory measures. These phenotypes ("clusters") were compared to elucidate statistically and clinically significant differences in outcomes.

METHODS

A total of 134,252 patients were gathered from the National Surgical Quality Improvement Program database between 2005 and 2015. "K-means" with 3 clusters was applied using 9 preoperative laboratory values: sodium, blood urea nitrogen (BUN), creatinine, albumin, bilirubin, white blood cell count, hematocrit, platelet count, and international normalized ratio of prothrombin values (INR). Outcome measures included 30-day readmissions, severe adverse events, and discharge to nonhome.

RESULTS

Cluster 2 was characterized by elevated preoperative BUN, creatinine, and INR and demonstrated almost twice the rate of adverse events (3.52% vs 2.20% and 2.22%), 30-day readmissions (6.39% vs 3.31% and 3.71%), and discharge to nonhome (47.97% vs 30.50% and 35.85%). Cluster 3 was characterized by a slightly higher risk of discharge to nonhome than cluster 1 and was overwhelmingly female (79.5% female, 35.8% discharge to nonhome). Cluster 1 represents the lowest-risk subgroup, experiencing the lowest rates of readmissions, adverse events, and discharge to nonhome.

CONCLUSION

Preoperative laboratory values, namely BUN, creatinine, and INR, are useful in identifying patients at risk of adverse outcomes. This analysis supports the existing surgical literature pushing for preoperative hydration as a targeted intervention to expedite recovery.

A protocol for a randomized controlled trial investigating the safety and cost-effectiveness of outpatient total hip arthroplasty

BACKGROUND

A significant proportion of the overall cost of total hip arthroplasty (THA) results from the inpatient hospital stay following the procedure. Considering the substantial and increasing number of these procedures performed annually, shifting to an outpatient model of care where the patient is discharged home the same day as their surgery represents a potential for significant cost savings. The potential significant impact of an outpatient care model on constrained healthcare budgets and lack of high-quality evidence regarding its effectiveness warrants a rigorous comparative trial. The purpose of this prospective, randomized controlled trial is to evaluate outpatient care pathways for THA. Specifically, our objectives are to compare the rate of serious adverse events and estimate the cost-effectiveness of outpatient compared to standard inpatient THA.

METHODS

We will include patients undergoing primary THA whom have an American Society of Anaesthetists status equal to or less than three, live within a 60-min driving distance of the institution and have an adult to accompany them home postoperatively and stay with them overnight. Consenting patients will be randomized to be discharged on the same day as surgery, as outpatients, or as inpatients according to standard of care (minimum of one night in hospital) using a modified Zelen consent model. The primary outcome measure is the incidence of serious adverse events at 30 days postoperative. Participants and their caregivers will complete secondary outcomes measures at each follow-up visit including patient-reported outcome measures and self-reported cost questionnaires.

DISCUSSION

This protocol is the first randomized trial to use blinding to evaluate outpatient THA compared to standard overnight stay and first to prospectively perform a full economic evaluation. It is also the first adequately powered trial to prospectively assess the safety of outpatient THA. Successful completion of this study could have the potential to provide clinical evidence for the role of outpatient THA in current practice.

TRIAL REGISTRATION

This study was retrospectively registered on ClinicalTrials.gov ( NCT03026764 ) on March 9th, 2016.

Degenerative Lumbar Spine Stenosis Consensus Conference: the Italian job. Recommendations of the Spinal Section of the Italian Society of Neurosurgery

In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.

Impact of Insurance and Practice Type on Access to Orthopaedic Sports Medicine

Background:

The Patient Protection Affordable Care Act has expanded Medicaid eligibility in recent years. However, the provisions of the act have not translated to improved Medicaid payments for specialists such as orthopaedic surgeons. The number of health care practitioners who accept Medicaid is already decreasing, with low reimbursement rates being cited as the primary reason for the trend.

Hypothesis:

Private practice orthopaedic groups will see patients with Medicaid or Medicare at lower rates than academic orthopaedic practices, and business days until appointment availability will be higher for patients with Medicaid and Medicare than those with private insurance.

Study Design:

Cross-sectional study.

Methods:

Researchers made calls to 2 regular-sized orthopaedic practices, 1 small orthopaedic practice, and 1 academic orthopaedic practice in each of the 50 states in the United States. Callers described a scenario of a recent injury resulting in a bucket-handle meniscal tear and an anterior cruciate ligament tear seen on magnetic resonance imaging at an outside emergency department. For a total of 194 practices, 3 separate telephone calls were made, each with a different insurance type. Data regarding insurance acceptance and business days until appointment were tabulated. Student t tests or analysis of variance for continuous data and χ² or Fisher exact tests for categorical data were utilized.

Results:

After completing 582 telephone calls, it was determined that 31.4% (n = 59) did not accept Medicaid, compared with 2.2% (n = 4) not accepting Medicare and 1% (n = 1) not accepting private insurance (P < .001). There was no significant association between type of practice and Medicaid refusal (P = 0.12). Mean business days until appointment for Medicaid, Medicare, and private insurance were 5.3, 4.1, and 2.9, respectively (P < .001).

Conclusions:

Access to care remains a significant burden for the Medicaid population, given a rate of Medicaid refusal of 32.2% across regular-sized orthopaedic practices. If Medicaid is accepted, time until appointment was significantly longer when compared with private insurance.

Readmissions After Distal Radius Fracture Open Reduction and Internal Fixation: An Analysis of 11,124 Patients

Purpose:

Distal radius fracture (DRF) open reduction and internal fixation (ORIF) is a common surgical procedure. This study assesses reasons and risk factors for readmission after DRF ORIF using the large sample size and follow-up of the American College of Surgeons National Surgical Quality Improvement Program database.

Methods:

Adult patients who underwent DRF ORIF were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Patient demographics, comorbidity status, hospital metrics, and 30-day perioperative outcomes were tabulated. Readmission, time to readmission, and reason for readmission were assessed. Reasons for readmission were categorized. Risk factors for readmission were assessed with multivariate analyses.

Results:

Of 11,124 patients who underwent DRF ORIF, 196 (1.76%) were readmitted within 30 days. Based on multivariate analysis, predictors of readmission (P < 0.05) were as follows: American Society of Anesthesiologist class > 3 (Odds ratio [OR] = 2.87), functionally dependent status (OR = 2.25), diabetes with insulin use (OR = 1.97), and staying in hospital after the index surgery (inpatient procedure, OR = 2.04). Readmissions occurred at approximately 14 days postoperatively. Of the recorded reasons for readmission after DRF ORIF, approximately one quarter were for surgical reasons, whereas over 75% of readmissions were for medical reasons unrelated to the surgery.

Conclusion:

This study found the rate of 30-day unplanned readmissions after DRF ORIF to be 1.76%. Demographic, comorbid, and perioperative factors predictive of readmission were defined. Most postoperative readmissions were for medical reasons unrelated to the surgical site and occurred at an average of approximately 2 weeks postoperatively. Multivariate analysis found that patients with increased American Society of Anesthesiologist class > 3, functional dependence, insulin-dependent diabetes, and those who underwent inpatient surgery for any reason were at a greater risk for readmission. Understanding these factors may aid in patient counseling and quality improvement initiatives, and this information should be used for risk stratification and risk adjustment of quality measures.

Risk Factors for 90-day Readmissions With Fluid and Electrolyte Disorders Following Posterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study of the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database.

OBJECTIVE

To identify risk factors for 30- and 90-day readmission due to fluid and electrolyte disorders following posterior lumbar fusion.

SUMMARY OF BACKGROUND DATA

Thirty- and 90-day readmission rates are important quality and outcome measures for hospitals and physicians. These measures have been tied to financial penalties for abnormally high rates of readmission. Furthermore, complex and high cost surgeries have been increasingly reimbursed in the form of bundled disease resource group payments, where any treatment within 90-day postdischarge is covered within the original bundled payment scheme.

METHODS

A total of 65,121 patients in the Healthcare Cost and Utilization Project Nationwide Readmissions Database met our inclusion criteria, of which 1128 patients (1.7%) were readmitted within 30 days, and 1669 patients (2.6%) were readmitted within 90 days due to fluid and electrolyte abnormalities. A bivariate analysis was performed to compare baseline characteristics between patients readmitted with fluid and electrolyte disorders and the remainder of the cohort. A multivariate regression analysis was then performed to identify independent risk factors for readmission due to fluid and electrolyte disorders at 30 and 90 days.

RESULTS

The strongest independent predictors of 30-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and drug use disorder. The five strongest predictors of 90-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and fluid and electrolyte disorders.

CONCLUSION

Patients with baseline liver disease, previously diagnosed fluid and electrolyte disorders, age older than 55 years, or drug use disorders are at higher risk for readmissions with fluid and electrolyte disorders following posterior lumbar fusion. Close monitoring of fluid and electrolyte balance in the perioperative period is essential to decrease complications and reduce unplanned readmissions.

LEVEL OF EVIDENCE

3.

Readmission following complex spine surgery in a prospective cohort of 679 patients - 2-years follow-up using the Spine AdVerse Event Severity (SAVES) system

BACKGROUND CONTEXT

Recent studies suggest that prospective registration more accurately reflects the true incidence of adverse events (AEs). To our knowledge, no previous study has investigated prospectively registered AEs' influence on hospital readmission following spine surgery.

PURPOSE

To determine the frequency and type of unplanned readmissions after complex spine surgery, and to investigate if prospectively registered AEs can predict readmissions.

DESIGN

This is a prospective, consecutive cohort study.

PATIENT SAMPLE

We conducted a single-center study of 679 consecutive patients who underwent complex spine surgery defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment.

OUTCOME MEASURES

The outcomes in this study were (1) readmission to any hospital department within 30 days of discharge and (2) readmission to a surgical spine center at any time in follow-up.

METHODS

All patients undergoing complex spine surgery, at our tertiary referral center, were consecutively, and prospectively, included from January 1 to December 31, 2013. Demographics and perioperative AEs were registered using the Spine AdVerse Events Severity (SAVES) system. Patients were followed for a minimum of two years. A competing risk survival model was used to estimate rates of readmissions with death as a competing risk. Patient characteristics, surgical parameters and perioperative AEs were analyzed to identify factors associated with readmission. Analyses of 30-day readmission were performed using logistic regression models. A proportional odds model, with death as competing risk, was used for readmissions to a spine center at any time in follow-up. Results were reported as odds ratios with 95% confidence intervals (95% CI).

RESULTS

Within 2 years of index discharge, 443 (65%) were readmitted. Only 20% of readmissions were to a spine center. Cumulative incidence (95% CI) of readmission was estimated to 13% (10%-16%) at 30 days, 26% (23%-30%) at 90 days, 50% (46%-54%) at 1 year, and 59% (55%-63%) at 2 years following discharge. Rates were markedly lower for readmissions to a spine center. Increased odds of 30-day readmission were correlated to intraoperative hypotension (p=.02) and major intraoperative blood loss (p<.01). Readmission to a spine center was associated with the number of instrumented vertebrae (p=.047), major intraoperative AE (p=.01), and intraoperative hypotension (p<.01).

CONCLUSIONS

To the best of our knowledge, this is the first study to analyze prospectively registered AEs' association to readmission up to 2 years after complex spine surgery. We found that readmissions were more frequent than previously reported when including readmissions to any department or hospital. Factors related to major intraoperative blood loss were associated to increased odds of readmission. This should be considered during planning of postoperative observation and care.