Capturing adverse events in elective orthopedic surgery: comparison of administrative, surgeon and reviewer reporting

Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study

BACKGROUND

The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries.

METHODS

Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors.

RESULTS

The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs.

CONCLUSIONS

This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.

Harms Reporting in Randomized Controlled Trials Underpinning the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines for Distal Radius Fractures

PURPOSE

The purpose of this study was to measure the harms-related reporting among randomized controlled trials (RCTs) cited as supporting evidence for the American Academy of Orthopaedic Surgeons clinical practice guidelines regarding the management of distal radius fractures.

METHODS

We adhered to the guidance for reporting metaresearch and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines throughout the course of this investigation. We used the American Academy of Orthopaedic Surgeons clinical practice guidelines for distal radius fractures available on Orthoguidelines.org. A linear regression analysis was conducted to model the relationship between the year of publication and the total Consolidated Standards of Reporting Trials percentage adherence over time.

RESULTS

Thirty-five RCTs were included in the final sample. The average number of Consolidated Standards of Reporting Trials Extension for Harms items adequately reported across all included RCTs was 9.2 (9.2/18, 50.9%). None of the included trials adequately reported all 18 items. Ten items had a compliance of more than 50% (10/18, 55.6%), 4 items had a compliance of 20%-50% (4/18, 22.2%), and 4 items had a compliance of less than 20% (4/18, 22.2%). The results of the linear regression model showed no significant improvement in Consolidated Standards of Reporting Trials Harms reporting over time.

CONCLUSIONS

Adverse events are incompletely reported among RCTs cited as supporting evidence for American Academy of Orthopaedic Surgeons clinical practice guidelines for the management of distal radius fractures.

CLINICAL RELEVANCE

Given our findings, specific attention should be paid to improving the standardization of the classification of adverse events to facilitate ease in the reporting process.

Pneumatic tourniquet versus no tourniquet in transfemoral amputation - a study protocol for a randomized controlled trial

BACKGROUND

Lower extremity amputation patients represent a frail group with extensive comorbidity. Transfemoral amputation is a high-risk procedure with 37-50% risk of mortality in the first year. Substantial blood loss during surgery increases the risk of anemic complications and death for these already weakened patients. The use of tourniquet during surgery may reduce blood loss, the need for blood transfusions, the related complications as well as the length of the surgery. However the use of tourniquet may be related to impaired wound healing and hence the use should be investigated in a randomized controlled trial. The primary aim of this study is to investigate the total blood loss and secondary to investigate differences in complications after transfemoral amputation between patients operated with or without tourniquet.

METHODS

The total blood loss is calculated using Nadlers approach. Based on data from a pilot series, the sample size was calculated to 124, allocated 1:1 in two groups of 62 participants to ensure detection of at least 200 mL difference in the total blood loss. The primary outcome is the total blood loss. Secondary outcomes are blood transfusions, duration of surgery, length of hospital stay and risk of complications within 90 days (re-admissions, re-operations and mortality). Explorative outcomes are 1 year mortality and re-operation risk. Further explorative outcomes are postoperative quality of life (questionnaire EQ-5D-5L) and evaluation of number of prosthesis users including evaluation of prosthesis-specific function measured 3, 6, and 12 months postoperatively.

DISCUSSION

The possibility to enhance patient safety is highly relevant and this trial will provide data for evidence based recommendations of best practice in amputation surgery.

TRIAL REGISTRATION

The trial is registered on ClinicalTrials.gov with ID: NCT05550623. Initial release: 13/09 2022.