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Hodgson JA, Cyr KL, Sweitzer B. Patient selection in ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:357-372. [PMID: 37938082 DOI: 10.1016/j.bpa.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/15/2022] [Accepted: 12/28/2022] [Indexed: 01/07/2023]
Abstract
Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.
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Affiliation(s)
- John A Hodgson
- Walter Reed National Military Medical Center and Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD, 20889, United States.
| | - Kyle L Cyr
- Walter Reed National Military Medical Center and Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD, 20889, United States.
| | - BobbieJean Sweitzer
- Medical Education, University of Virginia, Systems Director, Preoperative Medicine, Inova Health, 3300 Gallows Road, Falls Church, VA, 22042, United States.
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Total Hip Arthroplasty Revision Surgery: Impact of Morbidity on Perioperative Outcomes. J Arthroplasty 2021; 36:676-681. [PMID: 32854995 DOI: 10.1016/j.arth.2020.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/29/2020] [Accepted: 08/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Primary and revision total hip arthroplasty (THA) is increasingly performed in patients with high comorbidity burden. Its predominantly negative effects on outcomes are well understood in primary THA; however, the effects of morbidity on revision THA are unknown. Since revision procedures account for about 10% of the total surgical volume, we set out to investigate the effects of physical health status on perioperative outcomes in this setting. METHODS We queried our prospectively collected institutional database for patients who underwent revision THA at our institution (Orthopedic University Hospital Friedrichsheim, Frankfurt) between 2007 and 2011. Patients were classified according to American Society of Anesthesiologists (ASA) category and number of comorbidities. Subsequently, their impact on perioperative parameters was analyzed. RESULTS Our database revealed 294 cases of revision THA during the study period. Patients preoperatively classified as ASA 3 and 4 showed significantly higher rates of intraoperative and postoperative complications, transfusions, prolonged intensive care unit (ICU) stay, and total length of stay (LOS) compared to patients classified as ASA 1 and 2. Similarly, patients with >3 comorbidities presented with significantly elevated postoperative complications, ICU stay, and LOS. Particularly, preoperative cardiac diseases were associated with increased blood loss, transfusions, duration of surgery, postoperative complications, ICU stay, LOS, and re-revisions. CONCLUSION Poor physical health condition is associated with negative perioperative outcomes in revision THA. Especially cardiac comorbidities are linked to unfavorable outcomes, which have important implications for assessment of perioperative risk.
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Miura T, Kijima H, Konishi N, Kubota H, Yamada S, Tazawa H, Tani T, Suzuki N, Kamo K, Fujii M, Sasaki K, Kawano T, Iwamoto Y, Nagahata I, Miyakoshi N, Shimada Y. Preoperative medications is one of the factor affecting patient-reported outcomes after total hip arthroplasty. J Orthop 2020; 23:78-82. [PMID: 33424189 DOI: 10.1016/j.jor.2020.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/16/2020] [Accepted: 12/23/2020] [Indexed: 11/24/2022] Open
Abstract
Although the reported clinical outcomes of total hip arthroplasty (THA) for hip osteoarthritis are satisfactory, not all patients are completely satisfied. Thus, there is interest in predicting postoperative satisfaction before surgery. The influence of comorbidities and preoperative medications on the incidence of complications and duration of hospitalization following THA has become apparent. However, studies about the associations of preoperative medication with clinical outcomes of THA are limited. Therefore, this study aimed to clarify the relationship between preoperative medications and postoperative patient-reported outcomes. This retrospective cross-sectional multicenter study enrolled post-THA patients (79 patients, 90 hips) who were examined from February to March 2019 in eight general hospitals. Outcome measures included patient-reported outcome as Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) score. Preoperative medications were investigated from medical records. Medications were categorized, and analgesics were categorized into non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, pregabalin, duloxetine, neurotropin (an extract from inflammatory rabbit skin inoculated by vaccinia virus), and opioid. To identify the factors associated with JHEQ score, the patients were divided into lower (<55 score) and higher (≥55) JHEQ score groups. Spearman rank correlation coefficient (r) showed significant difference between the total number of preoperative medications and postoperative JHEQ movement subscale (r = -0.37, p < 0.01), mental subscale (r = -0.29, p < 0.01), and JHEQ (r = -0.30, p < 0.01) scores. In the multiple logistic regression analysis, only the total number of preoperative medications was identified as a risk factor for lower JHEQ score (p < 0.01). This study clarified an inverse correlation between the total preoperative medication count and postoperative outcomes and found that larger total count of preoperative medications is a risk factor of poor postoperative patient-reported outcomes of THA.
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Affiliation(s)
- Takanori Miura
- Department of Orthopedic Surgery, Kakunodate General Hospital, 3 Iwase, Kakunodate, Senboku, Akita, 014-0394, Japan.,Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Hiroaki Kijima
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan.,Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Natsuo Konishi
- Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Hitoshi Kubota
- Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Shin Yamada
- Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Hiroshi Tazawa
- Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Takayuki Tani
- Department of Orthopedic Surgery, Kakunodate General Hospital, 3 Iwase, Kakunodate, Senboku, Akita, 014-0394, Japan.,Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Norio Suzuki
- Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Keiji Kamo
- Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Masashi Fujii
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan.,Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Ken Sasaki
- Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Tetsuya Kawano
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan.,Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yosuke Iwamoto
- Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Itsuki Nagahata
- Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yoichi Shimada
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan.,Akita Hip Research Group (AHRG), 1-1-1 Hondo, Akita, 010-8543, Japan
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Abe N, Kakamu T, Kumagai T, Hidaka T, Masuishi Y, Endo S, Kasuga H, Fukushima T. Polypharmacy at admission prolongs length of hospitalization in gastrointestinal surgery patients. Geriatr Gerontol Int 2020; 20:1085-1090. [PMID: 32964583 PMCID: PMC7756353 DOI: 10.1111/ggi.14044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/19/2020] [Accepted: 09/02/2020] [Indexed: 12/22/2022]
Abstract
Aim Polypharmacy in elderly people is a social issue and has been reported to cause not only drug adverse events, but also falls, dysfunction and cognitive decline. Those events may trigger prolonged length of hospitalization. Therefore, the aim of this study was to investigate whether polypharmacy has a prolonging effect on hospitalization. Methods The study subjects were 584 patients in a university hospital in Japan who had been admitted for hepatectomy, pancreaticoduodenectomy, gastrectomy or colectomy, and to whom clinical pathways had been applied. In this study, polypharmacy was defined as taking five or more regular oral medications, and prolonged hospitalization was defined as hospitalization longer than that determined by the clinical pathway. Multiple logistic regression analysis was performed to investigate whether polypharmacy affects the length of hospitalization. Results The subjects were 348 males and 236 females, mean ± SD age of 65.8 ± 12.9 years. Among all subjects, 228 (39.0%) were receiving polypharmacy at admission, and the number of patients with prolonged hospitalization was 262 (44.9%). Multiple logistic regression analysis revealed that the following variables were significantly associated with prolonged hospitalization; polypharmacy (odds ratio = 1.532; 95% confidence interval = 1.010–2.327), age 50–59; 2.971 (1.216–7.7758), age 60–69; 2.405 (1.059–5.909), organ pancreas; 0.298 (0.122–0.708), operation time ≥386 min; 2.050 (1.233–3.432), intraoperative bleeding volume ≥401 mL; 2.440 (1.489–4.038), postoperative delirium; 2.395 (1.240–4.734), postoperative infection; 10.715 (4.270–33.059). Conclusion The current study revealed that polypharmacy at admission was an independent factor for prolonged hospitalization. In future, measures against polypharmacy are required, collaborating with outpatient clinics, family doctors and dispensing pharmacies. Geriatr Gerontol Int 2020; 20: 1085–1090..
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Affiliation(s)
- Natsuki Abe
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine: 1 Hikarigaoka, Fukushima, Japan
| | - Takeyasu Kakamu
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine: 1 Hikarigaoka, Fukushima, Japan
| | - Tomohiro Kumagai
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine: 1 Hikarigaoka, Fukushima, Japan
| | - Tomoo Hidaka
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine: 1 Hikarigaoka, Fukushima, Japan
| | - Yusuke Masuishi
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine: 1 Hikarigaoka, Fukushima, Japan
| | - Shota Endo
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine: 1 Hikarigaoka, Fukushima, Japan
| | - Hideaki Kasuga
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine: 1 Hikarigaoka, Fukushima, Japan
| | - Tetsuhito Fukushima
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine: 1 Hikarigaoka, Fukushima, Japan
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Springer B, Bechler U, Kolodny A, Rueckl K, Boettner F. Four questions to identify patients with ASA III or higher. Arch Orthop Trauma Surg 2019; 139:461-466. [PMID: 30617519 DOI: 10.1007/s00402-018-3078-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Increased age, obesity, and American Society of Anesthesiologists (ASA) Physical Status class III and IV have been reported as predictors for mortality and perioperative complications. High-volume institutions rely on central referral services as first contact point for patients. The current study reports on a simple four-step questionnaire to identify patients with ASA-physical status class III and IV to improve referral processes and optimize perioperative work ups. MATERIALS AND METHODS Seven hundred and seventy-five patients who called the physician referral service (PRS) at the author's institution and subsequently underwent surgery were enrolled in this study. The answers to the initial PRS questionnaire were analyzed. The study cohort consisted of 414 women (53.4%) and 361 men (46.6%) with an average age of 61.4 years (range 44-90 years) at the time of surgery. RESULTS Binary logistic regression revealed hypertension, diabetes mellitus (using medication), using blood thinner (other than Aspirin) and a number of 4-9 prescribed medication, respectively, as predictors for ASA III and IV. Receiver-operating characteristic (ROC) curve analysis identified a sensitivity of 82.4%, a specificity of 82.9%, and an accuracy of 82.8%, when two of these four questions are answered "yes". The area under the curve for this analysis was 0.876 [95% confidence interval (CI) 0.845-0.908]. Positive and negative likelihood ratios were 4.8 (95% CI 4.0-5.8) and 0.2 (95% CI 0.1-0.3), respectively. CONCLUSIONS This study revealed a simple four-step questionnaire to identify patients with ASA III or IV before a medical appointment. This helps to balance referrals between multiple providers in high-volume medical groups.
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Affiliation(s)
- Bernhard Springer
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Ulrich Bechler
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Andi Kolodny
- Physician Referral Service, Hospital for Special Surgery, New York, NY, USA
| | - Kilian Rueckl
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Friedrich Boettner
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.
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Zarling BJ, Sikora-Klak J, Bergum C, Markel DC. How Do Preoperative Medications Influence Outcomes After Total Joint Arthroplasty? J Arthroplasty 2017; 32:S259-S262. [PMID: 28578845 DOI: 10.1016/j.arth.2017.04.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/29/2017] [Accepted: 04/17/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Recent health care policy changes require hospitals and physicians to demonstrate improved quality. In 2012, a prospective database was formed with the Blue Cross and Blue Shield of Michigan to improve quality of care. The purpose of this study was to analyze patient preoperative medication as predictors of outcomes after total joint arthroplasty. METHODS Data were collected on patient's preoperative medications from 2012 to 2015 using a total joint arthroplasty database. Medications were categorized as antiplatelet, antimicrobial, anticoagulant, narcotic, steroid, insulin, or oral diabetes medication. Outcomes included hospital length of stay (LOS), discharge disposition/destination, and 90-day readmission. Univariate and multivariate regression analyses were performed. RESULTS A total of 3959 patients were studied. Eighty percent (3163 patients) were discharged home. The remainder (795) went to an extended-care facility (ECF). Patients discharged to an ECF were taking more medications (1.13 vs 0.80 in total knee arthroplasty; 1.18 vs 0.83 in total hip arthroplasty; P <.001). Patients who were readmitted took more medications (1.0 vs 0.85; P <.01). There were more discharges to an ECF in narcotic, steroid, and diabetes medication users. Patients taking anticoagulants, narcotics, insulin, and antiplatelets had greater readmission rates. There was a significant correlation between the number of medications and an increased LOS. CONCLUSION Patients taking more medications were more frequently discharged to an ECF and had increased LOS and readmission rates. Narcotics and diabetic medications had the greatest influence. Category and quantity of preoperative medications can be used as predictors of outcomes after arthroplasty surgery.
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Affiliation(s)
- Bradley J Zarling
- Wayne State University-Detroit Medical Center Orthopaedic Surgery Residency Program, Detroit, Michigan
| | - Jakub Sikora-Klak
- University of California San Diego Orthopaedic Surgery Residency Program, San Diego, California
| | - Chris Bergum
- Department of Orthopaedic Research, Providence-Providence Park Hospital, Southfield, Michigan
| | - David C Markel
- Wayne State University-Detroit Medical Center Orthopaedic Surgery Residency Program, Detroit, Michigan; Department of Orthopaedic Research, Providence-Providence Park Hospital, Southfield, Michigan; The CORE Institute, Southfield, Michigan
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Olthof M, Stevens M, Zijlstra WP, Bulstra SK, van den Akker-Scheek I. Medication Use is a Better Predictor of Length of Hospital Stay in Total Hip Arthroplasty Than the American Society of Anesthetists (ASA) Score. J Arthroplasty 2017; 32:24-27. [PMID: 27444851 DOI: 10.1016/j.arth.2016.06.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 06/06/2016] [Accepted: 06/11/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Length of hospital stay (LOS) greatly influences costs of total hip arthroplasty (THA). LOS is, among others, dependent on patient comorbidity. American Society of Anesthetists (ASA) scores are traditionally used as comorbidity measure, but simple medication-based measures may suffice. Therefore, the objective of the study is to determine if medication-based measures (count of medication and the medication-based index Chronic Disease Score [CDS]) have a surplus value compared to a diagnosis-based measure for comorbidity (ASA score) to predict LOS in THA. METHODS A retrospective cohort study. THA patients from 3 hospitals were included for 2009-2013, and demographic data, comorbidity (ASA score), and medication use (count of medication and CDS) were collected. A binomial regression model was used to compare the predictive ability of the medication-based and diagnosis-based measures. RESULTS A total of 2,282 THA patients were included. Number of medications proved a statistical significant predictor of LOS. LOS increased 6% (incidence rate ratios: 10.06 [confidence interval: 1.03-1.09]) with each medication. Neither the CDS nor the ASA score had a statistically significant relation to LOS. CONCLUSION The medication-based measure count of medication is a better predictor for LOS in THA than the CDS and ASA score. This simple measure also appears to have more clinical relevance, as it has a higher range in scores than diagnosis-based indexes and is easily applicable.
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Affiliation(s)
- Marijke Olthof
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Martin Stevens
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Wierd P Zijlstra
- Department of Orthopedics, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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