Patient Risk Profile for Unplanned 90-Day Emergency Department Visits Differs Between Total Hip and Total Knee Arthroplasty

Racial and Ethnic Disparities in Primary Total Knee Arthroplasty Outcomes: A Systematic Review and Meta-Analysis of Two Decades of Research

Racial disparities in outcomes following total knee arthroplasty (TKA) remain persistent. This systematic review and meta-analysis aims to comprehensively synthesize data between 2000-2020. An electronic search of studies was performed on PubMed, SCOPUS, and the Cochrane Library databases from January 1, 2000, and December 31, 2020. Random effects models were used to report unadjusted and adjusted estimates for a comprehensive list of care outcomes in TKA. 63 studies met PRISMA criteria. Black patients report greater odds of in-hospital mortality (odds ratio [OR]: 1.37, 95% CI: 1.00-1.59 (p = 0.049); adjusted OR [aOR]: 1.34, 95% CI: 1.09-1.64), in-hospital complications (OR: 1.31, 95% CI: 1.27-1.35), 30-day complications (aOR: 1.19, 95% CI: 1.07-1.33), infection (OR: 1.11, 95% CI: 1.07-1.16; aOR: 1.30, 95% CI: 1.16-1.46), bleeding (OR: 1.33, 95% CI: 1.03-1.71; aOR: 1.47, 95% CI: 1.23-1.75), peripheral vascular events (PVE) (aOR: 1.46, 95% CI: 1.11-1.92), length of stay (LOS) (OR: 1.20, 95% CI: 1.08-1.34), extended-LOS (aOR: 1.89, 95% CI: 1.53-2.33), discharge disposition (OR: 1.59, 95% CI: 1.29-1.96; aOR: 1.96, 95% CI: 1.70-2.25), 30-day (OR: 1.20, 95% CI: 1.13-1.27; aOR: 1.17 95% CI: 1.09-1.26) and 90-day (OR: 1.46, 95% CI: 1.17-1.82) readmission compared to White patients. Disparities in bleeding, extended-LOS, discharge disposition, PVE, and 30-day readmission were observed in Asian patients. Hispanic patients experienced disparities in extended LOS and discharge disposition, while Native-American patients had disparities in bleeding outcomes. Persistent racial disparities in TKA outcomes highlight a need for standardized outcome measures and comprehensive data collection across multiple racial groups to ensure greater healthy equity.

Preoperative Depression Screening for Primary Total Knee Arthroplasty: An Evaluation of Its Modifiability on Outcomes in Patients Who Have Depression

BACKGROUND

Few studies have evaluated preoperative depression screenings in patients who have depression. We studied whether depression screenings before total knee arthroplasty (TKA) were associated with lower: 1) medical complications; 2) emergency department (ED) utilizations and readmissions; 3) implant complications; and 4) costs.

METHODS

A nationwide sample from January 1, 2010, to April 30, 2021, was collected using an insurance database. Depression patients were 1:1 propensity-score matched based on those who had (n = 29,009) and did not have (n = 29,009) preoperative depression screenings or psychotherapy visits within 3 months of TKA. A case-matched population who did not have depression was compared (n = 144,994). A 90-day period was used to compare complications and health-care utilization and 2-year follow-up for periprosthetic joint infections (PJIs) and implant survivorship. Costs were 90-day reimbursements. Logistic regression models computed odds ratios (ORs) of depression screening on dependent variables. P values less than .001 were significant.

RESULTS

Patients who did not receive preoperative screening were associated with higher medical complications (18.7 versus 5.2%, OR: 4.15, P < .0001) and ED utilizations (11.5 versus 3.2%, OR: 3.93, P < .0001) than depressed patients who received screening. Patients who had screening had lower medical complications (5.2 versus 5.9%, OR: 0.88, P < .0001) and ED utilizations compared to patients who did not have depression (3.2 versus 3.8%, OR: 0.87, P = .0001). Two-year PJI incidences (3.0 versus 1.3%, OR: 2.63, P < .0001) and TKA revisions (4.3 versus 2.1%, OR: 2.46, P < .0001) were greater in depression patients who were not screened preoperatively versus screened patients. Depression patients who had screening had lower PJIs (1.3 versus 1.8%, OR: 0.74, P < .0001) compared to nondepressed patients. Reimbursements ($13,949 versus $11,982; P < .0001) were higher in depression patients who did not have screening.

CONCLUSIONS

Preoperative screening was associated with improved outcomes in depression patients.

LEVEL OF EVIDENCE

III.

C. Difficile Infection within 6 Months before TKA Is Associated with Increased Short-Term Complications

A history of Clostridium difficile infection (CDI) before total knee arthroplasty (TKA) may be a marker for poor patient health and could be used to identify patients with higher risks for complications after TKA. We compared the frequency of 90-day postoperative CDI, complications, readmissions, and associated risk factors in (1) patients experiencing CDIs more than 6 months before TKA, (2) patients experiencing CDIs in the 6 months before TKA, and (3) patients without a history of CDI. We identified patients who underwent primary TKAs from 2010 to 2019 and had a history of CDI before TKA (n = 7,195) using a national, all-payer database. Patients were stratified into two groups: those with CDIs > 6 months before TKA (n = 6,027) and those experiencing CDIs ≤ 6 months before TKA (n = 1,168). These patients were compared with the remaining 1.4 million patients without a history of CDI before TKA. Chi-square and unadjusted odds ratios (ORs) with 95% confidence intervals (CI) were used to compare complication frequencies. Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before TKA: OR 8.03 [95% CI 6.68-9.63]; p < 0.001; CDI ≤ 6 months before TKA: OR 59.05 [95% CI 49.66-70.21]; p < 0.001). Patients with a history of CDI before TKA were associated with higher unadjusted odds for 90-day complications and readmission compared with patients without a history of CDI before TKA. Other comorbidities and health metrics were not found to be associated with postoperative CDI (i.e., age, obesity, smoking, antibiotic use, etc.). CONCLUSION:  CDI before TKA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. CDI ≤ 6 months before TKA was associated with the highest odds for postoperative complications and readmissions. Providers should consider delaying TKA after CDI, if possible, to allow for patient recovery and eradication of infection.

Factors Associated With Higher Utilization of Outpatient Physical Therapy for Patients Who Have Undergone Primary Total Joint Arthroplasty: A Retrospective Cohort Study

Background

Research has identified predictive factors for inpatient complications and short-term recovery following total knee arthroplasty (TKA) and total hip arthroplasty (THA). Predictors that may influence length of care in outpatient physical therapy (PT) have yet to be examined. Doing so may improve the quality and efficiency of PT care following TKA and THA.

Purpose

The aim of this study was to determine factors associated with a higher utilization of outpatient PT visits for patients who have had primary THA or TKA.

Methods

A retrospective cohort study was performed using a population of 5147 patients who underwent THA and TKA between January 2017 and October 2022. Demographic and clinical factors were analyzed to determine which factors influenced PT utilization.

Results

Our multivariable linear regression model revealed that female sex, need for inpatient PT visits, and TKA as opposed to THA were significantly associated with an increase in outpatient PT visits. Older age, number of telerehabilitation visits, and history of depression were associated with fewer outpatient PT visits while accounting for all other variables.

Conclusions

The results of this retrospective analysis may help to identify some potential factors including TKA vs THA, patient age, and a history of depression that can be evaluated prospectively in future studies to determine whether they predict subsequent outpatient PT utilization.

Predictors of adverse safety events and unscheduled care among an outpatient parenteral antimicrobial therapy (OPAT) patient cohort

Background

Select circumstances require outpatient parenteral antimicrobial therapy (OPAT). The potency of OPAT agents presents an increased risk of adverse events and unscheduled medical care. We analyzed these outcomes among OPAT recipients as part of the implementation of a collaborative OPAT program.

Methods

Adult patients discharged home from an academic hospital with OPAT between January 2019 and June 2021 were included in this retrospective cohort; participants discharged between June 2020 and June 2021 were part of the collaborative OPAT program. Patients with cystic fibrosis were excluded. Data on patient characteristics and outcomes were collected from electronic medical records by two reviewers. Multivariable analysis was conducted to identify predictors of vascular access device (VAD) complications, adverse drug events (ADEs), and OPAT-related emergency department (ED) visits and rehospitalizations.

Results

Among 265 patients included in the cohort, 57 (21.5%) patients experienced a VAD complication; obesity [odds ratio (OR): 3.32; 95% confidence interval (CI): 1.38-8.73; p = 0.01) and multi-drug therapy (OR: 2.56; 95% CI: 1.21-5.39; p = 0.01) were associated with an increased odds of VAD complication. Eighty-two (30.9%) participants experienced an ADE; 30 (11.3%) experienced a severe/serious ADE. Lipo/glycopeptide receipt, (OR: 5.28; 95% CI: 1.89-15.43; p < 0.01) and Black/African American race (OR: 4.85; 95% (CI): 1.56-15.45; p < 0.01) were associated with an increased odds of severe/serious ADE. Inclusion in the OPAT collaborative was associated with a decreased odds of severe/serious ADE (OR: 0.26; 95% CI: 0.08-0.77; p = 0.01). Fifty-eight (21.9%) patients experienced an OPAT-related ED visit and 53 (20.0%) experienced an OPAT-related rehospitalization. VAD complication (OR: 2.37; 95% (CI): 1.15-4.86, p = 0.02) and ADEs (OR: 2.19; CI: 1.13-4.22; p = 0.02) were associated with OPAT-related ED visits. ADE was associated with 90-day OPAT-related rehospitalization (OR: 3.21; (CI): 1.59-6.58; p < 0.01).

Conclusion

Adverse safety events and OPAT-related unscheduled care occurred often in our cohort. A structured OPAT program that includes ID pharmacist antibiotic reconciliation may reduce rates of ADEs.

What are the Causes, Costs and Risk-Factors for Emergency Department Visits Following Primary Total Hip Arthroplasty? An Analysis of 1,018,772 Patients

BACKGROUND

Well-powered studies analyzing the relationship and nature of emergency department (ED) visits following primary total hip arthroplasties (THAs) are limited. The aim of this study was to: 1) compare baseline demographics of patients with/without an ED visit; 2) determine leading causes of ED visits; 3) identify patient-related risk factors; and 4) quantify 90-day episode-of-care healthcare costs divided by final diagnosis.

METHODS

Patients undergoing primary THA between January 1, 2010 and October 1, 2020 who presented to the ED within 90-days postoperatively were identified using the Mariner dataset of PearlDiver, yielding 1,018,772 patients. This included 3.9% (n = 39,439) patients who did and 96.1% (n = 979,333) who did not have an ED visit. Baseline demographics between the control/study cohorts, ED visit causes, risk-factors, and subsequent costs-of-care were analyzed. Using Bonferroni-correction, a P-value less than 0.002 was considered statistically significant.

RESULTS

Patients who presented to the ED post-operatively were most often aged 65-74 years old (41.09%) or female sex (55.60%). Nonmusculoskeletal etiologies comprised 66.8% of all ED visits. Risk factors associated with increased ED visits included alcohol abuse, depressive disorders, congestive heart failure, coagulopathy, and electrolyte/fluid derangements (P < .001 for all). Pulmonary ($28,928.01) and cardiac ($28,574.69) visits attributed to the highest costs of care.

CONCLUSION

Nonmusculoskeletal causes constituted the majority of ED visits. The top five risk factors associated with increased odds of ED visits were alcohol abuse, electrolyte/fluid derangements, congestive heart failure, coagulopathy, and depression. This study highlights potential areas of pre-operative medical optimization that may reduce ED visits following primary THA.

An analysis of 90-day emergency department visits after peripherally inserted central catheter (PICC) placement for prosthetic joint infection

OBJECTIVE

Research on complications with peripherally inserted central catheter (PICC) lines that are placed for the treatment of prosthetic joint infection (PJI) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is scarce. We investigated the timing, frequency, and risk factors for PICC complications during treatment of PJI after THA and TKA.

METHODS

We retrospectively queried an institutional database for THA and TKA patients from January 2015 through December 2020 that developed a PJI and required PICC placement at an academic, tertiary-care referral center.

RESULTS

The study included 889 patients (48.3% female) with a mean age of 64.6 years (range, 18.7-95.2) who underwent 435 THAs and 454 TKAs that were revised for PJI. The cohort had 275 90-day ED visits (30.9%), and 51 (18.5%) were PICC related. The average time from discharge to PICC ED visit was 26.2 days (range, 0.3-89.4). The most common reasons for a 90-day ED visit were issues related to the joint replacement or wound site (musculoskeletal or MSK; n = 116, 42.2%) and PICC complaints (n = 51, 18.5%). A multivariable logistic regression demonstrated that non-White race (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.24-4.04; P = .007) and younger age (OR, 0.98; 95% CI, 0.95-1.00; P = .035) were associated with PICC-related ED visits. Malposition/readjustment (41.2%) and occlusion (35.3%) were the most common PICC complications leading to ED presentation.

CONCLUSIONS

PICC complications are common after PJI treatment, accounting for nearly 20% of 90-day ED visits.

Emergency Department Visits Within 90 Days of Total Ankle Replacement

Background

Total ankle replacement (TAR) utilization in the United States has steeply increased in recent decades. Emergency department (ED) visits following TAR impacts patient satisfaction and health care costs and warrant exploration.

Methods

This retrospective cohort study utilized the 2010 to 2019 M91Ortho PearlDiver data set to identify TAR patients with at least 90 days of follow-up. PearlDiver contains billing claims data across all sites of care throughout the United States for all indications for care. Patient factors extracted included age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which surgery was performed, insurance plan, and postoperative hospital length of stay. Ninety-day postoperative ED visit incidence, timing, frequency, and primary diagnoses were identified and compared to 1-year postoperative ED visit baseline data. Univariate and multivariate logistic regression analyses were used to determine risk factors for ED visits.

Results

Of 5930 TAR patients identified, ED visits within 90 days were noted for 497 (8.4%) patients. Of all ED visits, 32.0% occurred within 2 weeks following surgery. Multivariate analysis revealed several predictors of ED utilization: younger age (odds ratio [OR] 1.35 per decade decrease), female sex (OR 1.20), higher ECI (OR 1.32 per 2-point increase), TAR performed in the western US (OR 1.34), and Medicaid coverage (OR 2.70; 1.71-4.22 relative to Medicare) (P < .05 each). Surgical site issues comprised 78.0% of ED visits, with surgical site pain (57.0%) as the most common problem.

Conclusion

Of 5930 TAR patients, 8.4% returned to the ED within 90 days of surgery, with predisposing demographic factors identified. The highest incidence of ED visits was in the first 2 postoperative weeks, and surgical site pain was the most common reason. Pain management pathways following TAR should be able to be adjusted to minimize the occurrence of postoperative ED visits, thereby improving patient experiences and decreasing health care utilization/costs.

Level of Evidence

Level III, retrospective cohort study.

Risk Factors for Preventable Emergency Department Use After Outpatient Hand Surgery

PURPOSE

Emergency department (ED) visits for postoperative concerns that could be safely addressed in outpatient clinics have an impact on cost, quality measures, and care workflows. Patient-reported data (PRD) may give unique insights into individual-level factors that predict overuse of health care resources, and guide opportunities for intervention and prevention. We investigated the relationship between preoperative PRD and preventable ED use after outpatient hand surgery to determine whether the preoperative PRD can be used to identify patients at higher odds of having preventable ED visits.

METHODS

All adult patients undergoing outpatient surgery at our hand center between January 1, 2018, and December 31, 2019, were included. Questionnaires, including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI) scales, were completed before surgery. We used our regional health information exchange to identify ED visits within 90 days of surgery.

RESULTS

Our cohort included 2,819 patients. Within 90 days after surgery, 106 (3.8%) had preventable ED visits. Race, insurance status, and transportation issues increased odds of a preventable ED visit. Multivariable models found that each 1-point increase in the preoperative PROMIS UE score was associated with 4% decreased odds of ED presentation (odds ratio, 0.96; 95% confidence interval, 0.94-0.99), and each 1-point increase in the preoperative PROMIS PI score was associated with 4% increased odds of ED presentation (odds ratio, 1.04; 95% confidence interval, 1.0-1.1). Any PROMIS UE or PI scores ≥1SDs worse than population norms increased the probability of a preventable ED visit, independent of other factors.

CONCLUSIONS

Worse preoperative PROMIS UE and PI scores were associated with increased odds of preventable ED visits. Preoperative PRD may allow for identification of outliers at higher risk for preventable ED use, and facilitate preventative interventions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.