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Gauthier CW, Bakaes YC, Kern EM, Kung JE, Hopkins JS, Hamilton CA, Bishop BC, March KA, Jackson JB. Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis. J Arthroplasty 2024; 39:1974-1981.e2. [PMID: 38403078 DOI: 10.1016/j.arth.2024.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND This study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery. METHODS A retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student's T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables. RESULTS Our study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty. CONCLUSIONS There was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non-total joint surgeons, although their patient population was more complex. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Chase W Gauthier
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Yianni C Bakaes
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Elizabeth M Kern
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Justin E Kung
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Jeffrey S Hopkins
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Corey A Hamilton
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Braxton C Bishop
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Kyle A March
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - J Benjamin Jackson
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
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Sharieff GQ, Uejo C. Sprint Team Approach Yields Rapid Improvement in Leapfrog Quality Indicators. J Healthc Manag 2024; 69:156-163. [PMID: 38467028 DOI: 10.1097/jhm-d-22-00223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
GOAL Patient safety and quality care are two critical areas that every healthcare organization strives to grow and improve upon. At Scripps Health, specific efforts reviewed for this article were implemented to reduce hospital-acquired conditions and hospital readmissions that are components of Centers for Medicare & Medicaid Services programs and Leapfrog Hospital Survey scores. METHODS Sprint teams, a novel approach to rapidly develop a checklist for lower-performing care improvement areas, were implemented after an internal review of existing tools and an evidence-based literature review. These areas included catheter-associated urinary tract infections (CAUTIs), central-line associated bloodstream infections (CLABSIs), Clostridioides difficile (C. diff.) and methicillin-resistant Staphylococcus aureus (MRSA) infections, chronic obstructive pulmonary disease (COPD) and heart failure readmissions, surgical site infections and handwashing, bar coding, and the computerized physician order entry components of Leapfrog scoring. The checklist for each area served as a teaching tool for staff and a guideline for case review to ensure that standard work was routinely performed. PRINCIPAL FINDINGS The sprint teams showed dramatic results in the initial focus areas. From a baseline standardized infection ratio (SIR) of 1.141 for CLABSIs, the sprint team reduced the SIR to 0.885 in Year 1 of the program and to 0.687 in Year 2. For CAUTIs, the SIR decreased from a baseline of 1.391 in Year 1 to 0.720 in Year 2. C. diff. infections fell from 0.422 to 0.315 in Year 1 and to 0.260 in Year 2. While the MRSA SIR did not improve during the first year, the MRSA reduction sprint team showed success in Year 2 with a decrease in the SIR from 0.537 to 0.245. Readmission reduction sprint teams focused on heart failure, COPD, and total hip and knee complications. The teams also achieved positive results in reducing readmissions by following checklists and reviewing each readmission case for justification. PRACTICAL APPLICATIONS Rapid change can be safely and effectively implemented with multidisciplinary sprint teams. Developed with an evidence-based, case review approach, sprint team checklists can help to standardize processes for the review of any infections or readmissions that occur in the inpatient arena.
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Ronan EM, Bieganowski T, Christensen TH, Robin JX, Schwarzkopf R, Rozell JC. The Impact of Hospital Exposures Prior to Total Knee Arthroplasty on Postoperative Outcomes. Arthroplast Today 2023; 23:101179. [PMID: 37712072 PMCID: PMC10498397 DOI: 10.1016/j.artd.2023.101179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/07/2023] [Accepted: 07/02/2023] [Indexed: 09/16/2023] Open
Abstract
Background Total knee arthroplasty (TKA) procedures are expected to grow exponentially in the upcoming years, highlighting the importance of identifying preoperative risk factors that predispose patients to poor outcomes. The present study sought to determine if preoperative healthcare events (PHEs) influenced outcomes following TKA. Methods This was a retrospective review of all patients who underwent TKA at a single institution from June 2011 to April 2022. Patients who had a PHE within 90 days of surgery, defined as an emergency department visit or hospital admission, were compared to patients with no history of PHE. Patients who underwent revision, nonelective, and/or bilateral TKA were excluded. Chi-squared analysis and independent sample t-tests were used to determine significant differences between demographic variables. All significant covariates were included in binary logistic regressions used to predict discharge disposition, 90-day readmission, and 1-year revision. Results Of the 10,869 patients who underwent TKA, 265 had ≥1 PHE. Patients who had a PHE were significantly more likely to require facility discharge (odds ratio [OR]: 1.662; P = .001) than patients who did not have a PHE. Any PHE predisposed patients to significantly higher 90-day readmission rates (OR: 2.173; P = .002). Patients with ≥2 PHEs were at a significantly higher risk of 1-year revision (OR: 5.870; P = .004) compared to patients without a PHE. Conclusions Our results demonstrate that PHEs put patients at significantly greater risk of facility discharge, 90-day readmission, and 1-year revision. Moving forward, consideration of elective surgery scheduling in the context of a recent PHE may lead to improved postoperative outcomes. Level III Evidence Retrospective Cohort Study.
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Affiliation(s)
- Emily M. Ronan
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | | | | | - Joseph X. Robin
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Joshua C. Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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Singh V, Anil U, Kurapatti M, Robin JX, Schwarzkopf R, Rozell JC. Emergency department visits following total joint arthroplasty: do revisions present a higher burden? Bone Jt Open 2022; 3:543-548. [PMID: 35801582 PMCID: PMC9350702 DOI: 10.1302/2633-1462.37.bjo-2022-0026.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits. Methods We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables. Results Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001). Conclusion ED visits present a significant burden to the healthcare system. Patients who undergo rTJA are more likely to present to the ED within 90 days following surgery compared to primary TJA patients. However, among patients in both cohorts who visited the ED, three-quarters did not require readmission. Future efforts should aim to develop cost-effective and patient-centred interventions that can aid in reducing preventable ED visits following TJA. Cite this article: Bone Jt Open 2022;3(7):543–548.
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Affiliation(s)
- Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Mark Kurapatti
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Joseph X. Robin
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Joshua C. Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
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Singh V, Kurapatti M, Anil U, Macaulay W, Schwarzkopf R, Davidovitch RI. Evaluation of Emergency Department Visits Following Total Joint Arthroplasty: Same-Day Discharge vs Non-Same-Day Discharge. J Arthroplasty 2022; 37:1017-1022. [PMID: 35181447 DOI: 10.1016/j.arth.2022.02.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty cases to determine the rate and reasons associated with 90-day ED presentations. METHODS We retrospectively reviewed all patients who underwent primary total hip arthroplasty and total knee arthroplasty between 2011 and 2021. The patients were separated into 2 cohorts: (1) SDD and (2) required a longer length of stay. The primary outcome was an ED visit within 90 days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the 2 groups while accounting for significant demographic variables. RESULTS Of the 24,933 patients included, 1,725 (7%) were SDD and 23,208 (93%) required a longer length of stay. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6% vs 4.0%, P = .004). However, when stratified based on the reason for ED visit, no single cause was significant between the 2 cohorts. The most commonly reported reasons were pain (32.1% vs 26.7%, P = .064) and other non-orthopedic-related medical issues (25.0% vs 29.5%, P = .206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0% vs 23.4%, P = .131). CONCLUSION Patients who underwent SDD were less likely to present to the ED within 90 days following their surgery compared to non-SDD. Approximately three fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Mark Kurapatti
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - William Macaulay
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Analysis of Risk Factors for High-Risk Patients Undergoing Total Joint Arthroplasty. Arthroplast Today 2022; 15:196-201.e2. [PMID: 35774885 PMCID: PMC9237280 DOI: 10.1016/j.artd.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
Background The purpose of this study is to evaluate and redefine patients at high risk for increased resource utilization and complications after total joint arthroplasty (TJA), so interventions may focus on patients standing to receive the most benefit. Material and methods This is a retrospective study of 787 patients undergoing primary unilateral TJA from September 1, 2020, to September 31, 2021. Patients were deemed to be at “high risk” based on criteria derived from published literature and triaged to an enhanced preoperative education program. Patients that were discharged to a skilled nursing facility, had a length of stay ≥ 2 days, returned to the emergency department, or readmitted within 30 days were classified as having a composite outcome. A univariate analysis compared patients who did and did not experience the composite outcome, and multivariate regression was performed to evaluate predictors of this endpoint. Results Differences in rates of 5 of the 28 risk factors were present between patients who did and did not experience composite outcomes. After controlling for other factors, African American race, planned discharge to skilled nursing facility, mental health conditions or drug use, cardiac, and neurologic conditions were predictive of the composite outcome. Patients who were reclassified as “high risk” with 1 or more of these characteristics, experienced longer length of stay and lower rates of home discharge than the rest of the population. Conclusion This study presents a profile of high-risk TJA patients that can be incorporated into clinical practice for risk stratification and targeted intervention.
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Pellegrini VD, Eikelboom JW, Evarts CM, Franklin PD, Garvin KL, Goldhaber SZ, Iorio R, Lambourne CA, Magaziner J, Magder L. Randomised comparative effectiveness trial of Pulmonary Embolism Prevention after hiP and kneE Replacement (PEPPER): the PEPPER trial protocol. BMJ Open 2022; 12:e060000. [PMID: 35260464 PMCID: PMC8905949 DOI: 10.1136/bmjopen-2021-060000] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/01/2022] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION More than 1 million elective total hip and knee replacements are performed annually in the USA with 2% risk of clinical pulmonary embolism (PE), 0.1%-0.5% fatal PE, and over 1000 deaths. Antithrombotic prophylaxis is standard of care but evidence is limited and conflicting. We will compare effectiveness of three commonly used chemoprophylaxis agents to prevent all-cause mortality (ACM) and clinical venous thromboembolism (VTE) while avoiding bleeding complications. METHODS AND ANALYSIS Pulmonary Embolism Prevention after HiP and KneE Replacement is a large randomised pragmatic comparative effectiveness trial with non-inferiority design and target enrolment of 20 000 patients comparing aspirin (81 mg two times a day), low-intensity warfarin (INR (International Normalized Ratio) target 1.7-2.2) and rivaroxaban (10 mg/day). The primary effectiveness outcome is aggregate of VTE and ACM, primary safety outcome is clinical bleeding complications, and patient-reported outcomes are determined at 1, 3 and 6 months. Primary data analysis is per protocol, as preferred for non-inferiority trials, with secondary analyses adherent to intention-to-treat principles. All non-fatal outcomes are captured from patient and clinical reports with independent blinded adjudication. Study design and oversight are by a multidisciplinary stakeholder team including a 10-patient advisory board. ETHICS AND DISSEMINATION The Institutional Review Board of the Medical University of South Carolina provides central regulatory oversight. Patients aged 21 or older undergoing primary or revision hip or knee replacement are block randomised by site and procedure; those on chronic anticoagulation are excluded. Recruitment commenced at 30 North American centres in December 2016. Enrolment currently exceeds 13 500 patients, representing 33% of those eligible at participating sites, and is projected to conclude in July 2024; COVID-19 may force an extension. Results will inform antithrombotic choice by patients and other stakeholders for various risk cohorts, and will be disseminated through academic publications, meeting presentations and communications to advocacy groups and patient participants. TRIAL REGISTRATION NCT02810704.
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Affiliation(s)
| | | | - C McCollister Evarts
- Orthopaedics and Physical Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Patricia D Franklin
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin L Garvin
- Orthopaedics and Physical Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Richard Iorio
- Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carol Ann Lambourne
- Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jay Magaziner
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Laurence Magder
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Wojtowicz AL, Al-Azzani W, Nåtman J, Rolfson O, Rogmark C, Cnudde PHJ. Hip arthroplasty for acute hip fracture in patients with neurological disorders: A report Of 9,702 cases from the Swedish arthroplasty register. Injury 2022; 53:1202-1208. [PMID: 34602245 DOI: 10.1016/j.injury.2021.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 09/16/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to investigate neurological disorder as a risk factor for dislocation following arthroplasty for acute hip fractures. We also analysed medical and surgical adverse events (AE), readmission, reoperation, revision, and mortality as secondary outcomes. METHODS A longitudinal cohort study using prospectively collected and aggregated data from the Swedish Hip Arthroplasty Register (SHAR) and the Swedish national patient register. All patients presenting with an acute hip fracture and treated with an arthroplasty in the period from 2005 to 2014 from the SHAR were identified. Patients in receipt of bilateral arthroplasties were excluded. Patients with a relevant pre-existing and diagnosed neurological disorder, as defined by ICD-10 codes, were identified (n = 9,702). All other cases (n = 29,411) were available for logistic regression propensity score matching. Patients were 1:1 matched on age, sex, Charlson comorbidity index, total versus hemiarthroplasty, head size, surgical approach, and year of surgery. Dislocations, adverse events, readmission, reoperation, revision, and mortality were studied using Kaplan-Meier analysis and Cox regression. RESULTS The risk of dislocations was higher for patients with neurological disorder (HR=1.19, CI 1.03- 1.39, p<0.05). Neurological disorder was associated with increased risk of encountering an adverse event (p<0.001 at 90-days); these patients were at higher risk of dying (HR=1.51, CI 1.47-1.56, p<0.001) however they were less likely to be readmitted (HR=0.73, CI 0.70- 0.76, p<0.001). No excess risks of reoperation (HR=1.02, CI 0.90-1.17; p = 0.73) or revision (HR=1.00, CI 0.86-1.17; p = 0.99) were identified in the study group. DISCUSSION Compared to matched controls, individuals with a preoperatively identified neurological diagnosis had higher rates of mortality, dislocations, and adverse events, but this cohort was not at increased risk of reoperation or revision. This study highlights an area of focus for future research to improve the long-term outcomes in patients with neurological disease undergoing arthroplasty for an acute hip fracture.
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Affiliation(s)
- Alex L Wojtowicz
- Hywel Dda University Health Board, Dept. of Orthopaedics, Prince Philip Hospital, Bryngwynmawr, Llanelli, SA14 8QF, NSW, United Kingdom; University of Bristol Medical School, First Floor, Tyndall Avenue, Bristol, BS8 1UD, United Kingdom.
| | - Waheeb Al-Azzani
- Hywel Dda University Health Board, Dept. of Orthopaedics, Prince Philip Hospital, Bryngwynmawr, Llanelli, SA14 8QF, NSW, United Kingdom.
| | - Jonatan Nåtman
- Swedish Arthroplasty Register, Registercentrum Västra Götaland, 413 45 Gothenburg, Sweden.
| | - Ola Rolfson
- Swedish Arthroplasty Register, Registercentrum Västra Götaland, 413 45 Gothenburg, Sweden; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Box 400, 405 30, Gothenburg, Sweden.
| | - Cecilia Rogmark
- Swedish Arthroplasty Register, Registercentrum Västra Götaland, 413 45 Gothenburg, Sweden; Dept. of Orthopaedics, Skåne University Hospital, Lund University, Södra Förstadsgatan 101, 205 02, Malmö, Sweden
| | - Peter H J Cnudde
- Hywel Dda University Health Board, Dept. of Orthopaedics, Prince Philip Hospital, Bryngwynmawr, Llanelli, SA14 8QF, NSW, United Kingdom; Swedish Arthroplasty Register, Registercentrum Västra Götaland, 413 45 Gothenburg, Sweden; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Box 400, 405 30, Gothenburg, Sweden.
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Creager A, Kleven AD, Kesimoglu ZN, Middleton AH, Holub MN, Bozdag S, Edelstein AI. The Impact of Pre-Operative Healthcare Utilization on Complications, Readmissions, and Post-Operative Healthcare Utilization Following Total Joint Arthroplasty. J Arthroplasty 2022; 37:414-418. [PMID: 34793857 PMCID: PMC8857028 DOI: 10.1016/j.arth.2021.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Identifying risk factors for adverse outcomes and increased costs following total joint arthroplasty (TJA) is needed to ensure quality. The interaction between pre-operative healthcare utilization (pre-HU) and outcomes following TJA has not been fully characterized. METHODS This is a retrospective cohort study of patients undergoing elective, primary total hip arthroplasty (THA, N = 1785) or total knee arthroplasty (TKA, N = 2159) between 2015 and 2019 at a single institution. Pre-HU and post-operative healthcare utilization (post-HU) included non-elective healthcare utilization in the 90 days prior to and following TJA, respectively (emergency department, urgent care, observation admission, inpatient admission). Multivariate regression models including age, gender, American Society of Anesthesiologists, Medicaid status, and body mass index were fit for 30-day readmission, Centers for Medicare and Medicaid services (CMS)-defined complications, length of stay, and post-HU. RESULTS The 30-day readmission rate was 3.2% and 3.4% and the CMS-defined complication rate was 3.8% and 2.9% for THA and TKA, respectively. Multivariate regression showed that for THA, presence of any pre-HU was associated with increased risk of 30-day readmission (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.48-5.50, P = .002), CMS complications (OR 2.42, 95% CI 1.27-4.59, P = .007), and post-HU (OR 3.65, 95% CI 2.54-5.26, P < .001). For TKA, ≥2 pre-HU events were associated with increased risk of 30-day readmission (OR 3.52, 95% CI 1.17-10.61, P = .026) and post-HU (OR 2.64, 95% CI 1.29-5.40, P = .008). There were positive correlations for THA (any pre-HU) and TKA (≥2 pre-HU) with length of stay and number of post-HU events. CONCLUSION Patients who utilize non-elective healthcare in the 90 days prior to TJA are at increased risk of readmission, complications, and unplanned post-HU. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ashley Creager
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Andrew D. Kleven
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Austin H. Middleton
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Meaghan N. Holub
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Serdar Bozdag
- Department of Computer Science and Engineering, University of North Texas, Denton, TX
| | - Adam I. Edelstein
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI
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Kulshrestha V, Sood M, Kumar S, Sood N, Kumar P, Padhi PP. Does Risk Mitigation Reduce 90-Day Complications in Patients Undergoing Total Knee Arthroplasty? A Cohort Study. Clin Orthop Surg 2022; 14:56-68. [PMID: 35251542 PMCID: PMC8858904 DOI: 10.4055/cios20234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 11/08/2022] Open
Abstract
Background With ever-increasing demand for total knee arthroplasty (TKA), most healthcare systems around the world are concerned about its socioeconomic burden. Most centers have universally adopted well-defined clinical care pathways to minimize adverse outcomes, maximize volume, and limit costs. However, there are no prospective comparative trials reporting benefits of these risk mitigation (RM) strategies. Methods This is a prospective cohort study comparing post-TKA 90-day complications between patients undergoing RM before surgery and those following a standard protocol (SP). In the RM group, we used a 20-point checklist to screen for modifiable risk factors and evaluate the need for optimizing non-modifiable comorbidities. Only when optimization goals were achieved, patients were offered TKA. Results TKA was performed in 811 patients in the SP group and in 829 in the RM group, 40% of which were simultaneous bilateral TKA. In both groups, hypertension was the most prevalent comorbidity (48%), followed by diabetes (20%). A total of 43 (5.3%) procedure-related complications were seen over the 90-day postoperative period in the SP group, which was significantly greater than 26 (3.1%) seen in the RM group (p = 0.039). The commonest complication was pulmonary thromboembolic, 6 in each group. Blood transfusion rate was higher in the SP group (6%) than in the RM group (< 1%). Conclusions Screening and RM can reduce 90-day complications in patients undergoing TKA.
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Affiliation(s)
- Vikas Kulshrestha
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
| | - Munish Sood
- Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Chandimandir, Chandigarh, India
| | - Santhosh Kumar
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
| | - Nikhil Sood
- Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Chandimandir, Chandigarh, India
| | - Pradeep Kumar
- Department of Orthopaedics and Major Rehabilitation Center, Air Force Hospital Kanpur, Kanpur, India
| | - Prashanth P Padhi
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
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Chun DS, Leonard AK, Enchill Z, Suleiman LI. Racial Disparities in Total Joint Arthroplasty. Curr Rev Musculoskelet Med 2021; 14:434-440. [PMID: 34626322 PMCID: PMC8733080 DOI: 10.1007/s12178-021-09718-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The primary aim of this review was to evaluate recently published total joint arthroplasty (TJA) studies in order to accurately summarize the current concepts regarding racial and ethnic disparities in total joint arthroplasty. RECENT FINDINGS Many studies found that racial and ethnic disparities in TJA are present in all phases of arthroplasty care including access to, utilization of, and postoperative outcomes after TJA. Factors that limit patient access to TJA-increased patient comorbidities, lower socioeconomic status, and Medicaid/uninsured status-are also disproportionately associated with underrepresented patient populations. Minority patients are more likely to require more intensive postoperative rehabilitation and non-home discharge placement. This in turn potentially adds additional concerns regarding hospital/provider reimbursement in light of the current Medicare/Medicaid model for arthroplasty surgeons, thus creating a recurrent cycle in which disparities in TJA reflect the complex interplay of overall health disparities and access inequalities associated with racial and ethnic biases. Literature demonstrating evidenced-based interventions to minimize these disparities is sparse, but the multifactorial cause of disparities in TJA highlights the need for multifaceted solutions on both a systemic and individual level.
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Affiliation(s)
- Danielle S Chun
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA
| | - Annemarie K Leonard
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA
| | - Zenaida Enchill
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA
| | - Linda I Suleiman
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA.
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12
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Doman DM, Young AM, Buller LT, Deckard ER, Meneghini RM. Comparison of Surgical Site Complications With Negative Pressure Wound Therapy vs Silver Impregnated Dressing in High-Risk Total Knee Arthroplasty Patients: A Matched Cohort Study. J Arthroplasty 2021; 36:3437-3442. [PMID: 34140207 DOI: 10.1016/j.arth.2021.05.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Closed incision negative pressure wound therapy (ciNPWT) may reduce surgical site complications following total joint arthroplasty. Although unlikely necessary for all patients, the criteria for utilizing ciNPWT in primary total knee arthroplasty (TKA) remain poorly defined. This study's purpose was to compare the incidence of incisional wound complications, non-incisional complications (ie, dressing reactions), reoperations, and periprosthetic joint infections (PJIs) among a group of high-risk primary TKA patients treated with ciNPWT vs an occlusive silver impregnated dressing. METHODS One hundred thirty high-risk primary TKA patients treated with ciNPWT were 1:1 propensity matched and compared to a historical control group treated with an occlusive silver impregnated dressing. High-risk criteria included the following: active tobacco use, diabetes mellitus, body mass index >35 kg/m2, autoimmune disease, chronic kidney disease, Staphylococcus aureus nasal colonization, and non-aspirin anticoagulation. RESULTS Age, gender, and risk factor profile were comparable between cohorts. The ciNPWT cohort had significantly fewer incisional wound complications (6.9% vs 16.2%; P = .031) and significantly more non-incisional complications (16.9% vs 1.5%; P < .001). No dressing reactions required clinical intervention. There were no differences in reoperations or periprosthetic joint infections (P = 1.000). In multivariate analysis, occlusive silver impregnated dressings (odds ratio 2.9, 95% confidence interval 1.3-6.8, P = .012) and non-aspirin anticoagulation (odds ratio 2.5, 95% confidence interval 1.1-5.6, P = .028) were associated with the development of incisional wound complications. CONCLUSION Among high-risk patients undergoing primary TKA, ciNPWT decreased incisional wound complications when compared to occlusive silver impregnated dressings, particularly among those receiving non-aspirin anticoagulation. Although an increase in dressing reactions was observed, the clinical impact was minimal.
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Affiliation(s)
- David M Doman
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA
| | | | - Leonard T Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Evan R Deckard
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Abstract
OBJECTIVES To determine the reliability of self-reported smoking status in the orthopaedic trauma population and determine if certain patient factors might predispose inaccurate self-reported smoking cessation. DESIGN Prospective. SETTING Level I trauma center. PATIENTS Two hundred forty-seven orthopaedic trauma patients were included in the study. INTERVENTION In-office measurement of exhaled carbon monoxide (CO). MAIN OUTCOME MEASUREMENTS Self-reported smoking cessation with exhaled CO measurements. RESULTS A total of 906 self-reported surveys were completed over 4 follow-up visits. Of the responses indicating smoking cessation (n = 174), 12.6% [95% confidence interval (CI), 0.081-0.185] reported smoking cessation with positive CO readings, suggesting inaccurate self-reporting of smoking status. Over 20% of those patients inaccurately reporting abstinence did so more than once. The odds of inaccurate self-reporting was 3 times higher in patients with no insurance or government insurance [odds ratio (OR), 3.5; 95% CI, 1.1-11.0; P = 0.043] and in the unemployed (OR, 3.3; 95% CI, 0.97-8.57; P = 0.049). CONCLUSIONS Self-reported smoking status in the orthopaedic population is fairly reliable, with 13% of patient's inaccurately self-reporting smoking cessation despite knowing their smoking status was being measured. Clinicians should be aware of the potential for inaccuracy in self-reported smoking cessation, particularly in patients with the identified socioeconomic factors. Point-of-care testing before elective trauma procedures to confirm smoking status might have a role if the procedure outcome is highly dependent on smoking status. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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14
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Kerbel YE, Johnson MA, Barchick SR, Cohen JS, Stevenson KL, Israelite CL, Nelson CL. Preoperative risk stratification minimizes 90-day complications in morbidly obese patients undergoing primary total knee arthroplasty. Bone Joint J 2021; 103-B:45-50. [PMID: 34053302 DOI: 10.1302/0301-620x.103b6.bjj-2020-2409.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients. METHODS We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m2 (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m2, n = 512); obese (BMI 30 kg/m2 to 39.9 kg/m2, n = 748); and morbidly obese (BMI > 40 kg/m2, n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes. RESULTS Obese patients had a significantly increased rate of discharge to a rehabilitation facility compared with non-obese patients (38.7% (426/1,102) vs 26.0% (133/512), respectively; p < 0.001). When stratified by BMI, discharge to a rehabilitation facility remained significantly higher compared with non-obese (26.0% (133)) in both obese (34.2% (256), odds ratio (OR) 1.6) and morbidly obese (48.0% (170), OR 3.1) patients (p < 0.001). However, there was no significant difference in unexpected ICU transfer (0.4% (two) non-obese vs 0.9% (seven) obese (OR 2.5) vs 1.7% (six) morbidly obese (OR 5.4); p = 0.054), visits to the ED (8.6% (44) vs 10.3% (77) (OR 1.3) vs 10.5% (37) (OR 1.2); p = 0.379), readmissions (4.5% (23) vs 4.0% (30) (OR 1.0) vs 5.1% (18) (OR 1.4); p = 0.322), or reoperations (2.5% (13) vs 3.3% (25) (OR 1.2) vs 3.1% (11) (OR 0.9); p = 0.939). CONCLUSION With the use of a preoperative RST, morbidly obese patients had similar rates of short-term postoperative adverse outcomes after primary TKA as non-obese patients. This supports the assertion that morbidly obese patients can safely undergo TKA with appropriate perioperative optimization and monitoring. Cite this article: Bone Joint J 2021;103-B(6 Supple A):45-50.
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Affiliation(s)
- Yehuda E Kerbel
- Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mitchell A Johnson
- Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen R Barchick
- Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jordan S Cohen
- Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Craig L Israelite
- Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles L Nelson
- Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Mukiibi W, Maharaj Z, Sekeitto AR, Mokete L, Pietrzak JRT. The management of displaced intracapsular femoral neck fractures at a Sub-Saharan Academic Hospital. SICOT J 2021; 7:34. [PMID: 34009118 PMCID: PMC8132601 DOI: 10.1051/sicotj/2021023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 03/20/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Femoral neck fractures (FNFs) remain "the unsolved fracture" and optimal management is still controversial. The outcomes of hemiarthroplasty (HA) and total hip arthroplasty (THA) in the treatment of FNFs are inconsistent. As demand for management of FNFs continues to grow globally, evaluation of the appropriateness of treatment remains essential, particularly in resource-constrained settings. METHODS We conducted a retrospective chart review of all patients presenting with isolated low energy intracapsular FNFs to an orthopaedic academic unit in Sub-Saharan Africa from January 2016 to April 2019. The decision regarding HA or THA was largely based upon the Sernbo score and ASA classification. The majority of patients with a Sernbo score of ≥15 and ASA class III or better received THA. RESULTS There were 117 patients (33 male/84 female) 72 years (33-97 years) with FNFs who underwent 56 THA and 61 HA between January 2016 and April 2019. The mean Sernbo score was 15.99 overall (range 8-20) and was 18.95 (11-20) for THA patients compared to 14.46 (8-20) for HA patients (p = 0.042). Time taken from admission to the theatre was 8-19 days (1-22) and 7-61 days (2-31) for HA and THA respectively. The average length of stay (LOS) was 16.04 days and the main reason for same-day cancellations was the lack of post ICU/High Care beds. The 30-day mortality rates were 1.78% and 4.91% for THA and HA patients, respectively (p = 0.07). The mortality rate for patients with a Sernbo score < 15 was 15.38% overall, 8.93% for THA patients, and 21.31% for HA patients, respectively (p = 0.021). CONCLUSION The 30-day mortality rate was comparable with published rates from developed countries. There were significant delays in time to theatre, high rates of same-day surgical cancellations, and increased LOS for both HA and THA. These factors play a cumulative role in inflating costs on a strained healthcare system in a developing country. A multidisciplinary approach including the care provision of a specialized geriatric unit is recommended. Retrospective Study, Level III evidence.
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Affiliation(s)
- Winifred Mukiibi
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Arthroplasty Unit, Department of Orthopaedics, Charlotte Maxeke Johannesburg Hospital, University of Witwatersrand 2000 Johannesburg South Africa
| | - Zia Maharaj
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Arthroplasty Unit, Department of Orthopaedics, Charlotte Maxeke Johannesburg Hospital, University of Witwatersrand 2000 Johannesburg South Africa
| | - Allan Roy Sekeitto
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Arthroplasty Unit, Department of Orthopaedics, Charlotte Maxeke Johannesburg Hospital, University of Witwatersrand 2000 Johannesburg South Africa
| | - Lipalo Mokete
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Arthroplasty Unit, Department of Orthopaedics, Charlotte Maxeke Johannesburg Hospital, University of Witwatersrand 2000 Johannesburg South Africa
| | - Jurek Rafal Tomasz Pietrzak
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Arthroplasty Unit, Department of Orthopaedics, Charlotte Maxeke Johannesburg Hospital, University of Witwatersrand 2000 Johannesburg South Africa
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Hinton ZW, Fletcher AN, Ryan SP, Wu CJ, Bolognesi MP, Seyler TM. Body Mass Index, American Society of Anesthesiologists Score, and Elixhauser Comorbidity Index Predict Cost and Delay of Care During Total Knee Arthroplasty. J Arthroplasty 2021; 36:1621-1625. [PMID: 33419618 DOI: 10.1016/j.arth.2020.12.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Body mass index (BMI), American Society of Anesthesiologists (ASA) score, and Elixhauser Comorbidity Index are measures that are utilized to predict perioperative outcomes, though little is known about their comparative predictive effects. We analyzed the effects of these indices on costs, operating room (OR) time, and length of stay (LOS) with the hypothesis that they would have a differential influence on each outcome variable. METHODS A retrospective review of the institutional database was completed on primary TKA patients from 2015 to 2018. Univariable and multivariable models were constructed to evaluate the strength of BMI, ASA, and Elixhauser comorbidities for predicting changes to total hospital and surgical costs, OR time, and LOS. RESULTS In total, 1313 patients were included. ASA score was independently predictive of all outcome variables (OR time, LOS, total hospital and surgical costs). BMI, however, was associated with intraoperative resource utilization through time and cost, but only remained predictive of OR time in an adjusted model. Total Elixhauser comorbidities were independently predictive of LOS and total hospital cost incurred outside of the operative theater, though they were not predictive of intraoperative resource consumption. CONCLUSION Although ASA, BMI, and Elixhauser comorbidities have the potential to impact outcomes and cost, there are important differences in their predictive nature. Although BMI is independently predictive of intraoperative resource utilization, other measures like Elixhauser and ASA score were more indicative of cost outside of the OR and LOS. These data highlight the differing impact of BMI, ASA, and patient comorbidities in impacting cost and time consumption throughout perioperative care.
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Affiliation(s)
- Zoe W Hinton
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
| | | | - Sean P Ryan
- Department of Orthopedic Surgery, Duke University, Durham, NC
| | - Christine J Wu
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
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17
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Buchalter DB, Kirby DJ, Teo GM, Iorio R, Aggarwal VK, Long WJ. Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Reduce the Rate of Early Periprosthetic Joint Infection After Primary Total Knee Arthroplasty. J Arthroplasty 2021; 36:286-290.e1. [PMID: 32919848 DOI: 10.1016/j.arth.2020.07.064] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Vancomycin powder and dilute povidone-iodine lavage (VIP) was introduced to reduce the incidence of periprosthetic joint infection (PJI) in high-risk total knee arthroplasty (TKA) patients. We hypothesize that VIP can reduce the incidence of early PJI in all primary TKA patients, regardless of preoperative risk. METHODS An infection database of primary TKAs performed before a VIP protocol was implemented (January 2012-December 2013), during a time when only high-risk TKAs received VIP (January 2014-December 2015), and when all TKAs received VIP (January 2016-September 2019) at an urban, university-affiliated, not-for-profit orthopedic hospital was retrospectively reviewed to identify patients with PJI. Criteria used for diagnosis of PJI were the National Healthcare Safety Network and Musculoskeletal Infection Society guidelines. RESULTS VIP reduced early primary TKA PJI incidence in both the high-risk and all-risk cohorts compared with the pre-VIP cohort by 44.6% and 56.4%, respectively (1.01% vs 0.56% vs 0.44%, P = .0088). In addition, after introducing VIP to all-risk TKA patients, compared with high-risk TKA patients, the relative risk of PJI dropped an additional 21.4%, but this finding did not reach statistical significance (0.56% vs 0.44%, P = .4212). There were no demographic differences between the 3 VIP PJI cohorts. CONCLUSION VIP is associated with a reduced early PJI incidence after primary TKA, regardless of preoperative risk. With the literature supporting its safety and cost-effectiveness, VIP is a value-based intervention, but given the nature of this historical cohort study, a multicenter randomized controlled trial is underway to definitively confirm its efficacy.
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Affiliation(s)
| | - David J Kirby
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Greg M Teo
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Richard Iorio
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - William J Long
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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18
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Iorio R, Yu S, Anoushiravani AA, Riesgo AM, Park B, Vigdorchik J, Slover J, Long WJ, Schwarzkopf R. Vancomycin Powder and Dilute Povidone-Iodine Lavage for Infection Prophylaxis in High-Risk Total Joint Arthroplasty. J Arthroplasty 2020; 35:1933-1936. [PMID: 32247676 DOI: 10.1016/j.arth.2020.02.060] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/18/2020] [Accepted: 02/25/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). Vancomycin powder is reported to be effective in preventing infection in spine surgery. We hypothesize that a "vanco-povidone protocol" (VIP) for TJA patients at high risk for infection is safe and will decrease the rate of PJI. METHODS High-risk TJA patients (body mass index >40, active smokers, American Society of Anesthesiologists ≥3, immunosuppression/diabetes, methicillin-resistant Staphylococcus aureus colonization, revision surgery) utilizing VIP were compared to a high-risk historical cohort not treated with VIP, at a single institution. VIP consisted of dilute povidone-iodine lavage followed by application of vancomycin powder prior to wound closure. Primary endpoint was PJI within 3 months postoperatively. RESULTS The historical, high-risk control cohort consisted of 3251 patients with a PJI incidence of 1.8%. A total of 1413 subjects received the VIP protocol with a PJI incidence of 1.3%. There was a 27.8% risk reduction when compared to the control group of high-risk subjects not treated with the VIP. There were no medical complications secondary to the use of VIP, no increase in vancomycin-resistant enterococcus or vancomycin-resistant Staph aureus, and no cases of acute renal impairment secondary to application of the local vancomycin. CONCLUSIONS PJI remains a common complication of TJA, especially in high-risk populations. This study indicates that a protocol of dilute povidone-iodine lavage combined with topical vancomycin powder is safe and may reduce PJI incidence in high-risk TJA patients. Due to low, current PJI rates, a multi-institutional randomized controlled trial is necessary to assess interventions that minimize the risk of PJI. LEVEL OF EVIDENCE Retrospective Observational Cohort.
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Affiliation(s)
- Richard Iorio
- Department of Orthpaedic Surgery, Brigham Health, Brigham and Women's Hospital, Boston, MA
| | - Stephen Yu
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Afshin A Anoushiravani
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Aldo M Riesgo
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Brian Park
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Jonathan Vigdorchik
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - James Slover
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - William J Long
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
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Curtis GL, Jawad M, Samuel LT, George J, Higuera-Rueda CA, Little BE, Darwiche HF. Incidence, Causes, and Timing of 30-Day Readmission Following Total Knee Arthroplasty. J Arthroplasty 2019; 34:2632-2636. [PMID: 31262621 DOI: 10.1016/j.arth.2019.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 05/28/2019] [Accepted: 06/04/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It is important to study the incidence and causes of readmissions in order to understand why they occur and how to reduce them. This study looks at a national sample of patients following total knee arthroplasty (TKA) to identify incidences, trends, causes, and timing of 30-day readmissions. METHODS Patients undergoing primary TKA from 2012 to 2016 in the American College of Surgeons National Surgical Quality Improvement Program database were identified (n = 197,192). Patients with fractures (n = 177), nonelective surgery (n = 2234), bilateral TKA (n = 5483), and cases with unknown readmission status (n = 1047) were excluded, leaving a total of 188,251 cases. Linear regression analysis was used to determine trends over time. RESULTS The incidence of overall 30-day readmission following primary TKA from 2012 to 2016 was 3.19% (6014/188,251), with significant decreases in readmission rates during this time (β = -0.001, P < .001). The top 5 causes of readmission included superficial surgical site infection (SSI; 9.7%), non-SSI infection (9.5%), cardiovascular complications (CV; 9.3%), gastrointestinal complications (8.8%), and venous thromboembolisms (8.8%). The most common cause of readmission during postoperative week 1 was CV complications (12.2%), week 2 was superficial SSI (11.6%), week 3 was deep SSI (11.4%), and week 4 was deep SSI (12.4%). CONCLUSION Overall, 30-day readmissions following TKA were found to significantly decline from 2012 to 2016. The most common causes of overall readmission included superficial SSI, non-SSI infection, CV complications, gastrointestinal complications, and venous thromboembolisms. However, the most common causes of readmission changed from week to week postoperatively. This data may help institutions develop policies to prevent unplanned readmissions following TKA.
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Affiliation(s)
- Gannon L Curtis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Michael Jawad
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Jaiben George
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Bryan E Little
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI
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Greiwe RM, Spanyer JM, Nolan JR, Rodgers RN, Hill MA, Harm RG. Improving Orthopedic Patient Outcomes: A Model to Predict 30-Day and 90-Day Readmission Rates Following Total Joint Arthroplasty. J Arthroplasty 2019; 34:2544-2548. [PMID: 31272826 DOI: 10.1016/j.arth.2019.05.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/20/2019] [Accepted: 05/29/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Over the next 10-15 years, there is expected to be an exponential increase in the number of total joint arthroplasties in the American population. This, combined with rising costs of total joint arthroplasty and more recent changes to the reimbursement payment models, increases the demand to perform quality, cost-effective total joint arthroplasties. The purpose of this study is to build models that could be used to estimate the 30-day and 90-day readmission rates for patients undergoing total joint arthroplasty. METHODS A retrospective review of patients admitted to a single hospital, over the course of 56 months, for total joint arthroplasty was performed. The goal is to identify patients with readmission in a 30-day or 90-day period following discharge from the hospital. Binary logistic regression was used to build predictive models that estimate the likelihood of readmission based on a patient's risk factors. RESULTS Of 5732 patients identified for this study, 237 were readmitted within 30 days, while 547 were readmitted within 90 days. Age, body mass index, gender, discharge disposition, occurrence of cardiac dysrhythmias and heart failure, emergency department visits, psychiatric diagnoses, and medication counts were all found to be associated with 30-day admission rates. Similar associations were found at 90 days, with the exclusion of age and psychiatric drug use, and the inclusion of intravenous drug abuse, narcotic medications, and total joint arthroplasty within 12 months. CONCLUSION There are patient variables, or risk factors, that serve to predict the likelihood of readmission following total joint arthroplasty.
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Affiliation(s)
| | | | - Joseph R Nolan
- Department of Mathematics and Statistics, Northern Kentucky University, Highland Heights, KY
| | | | - Misti A Hill
- St. Elizabeth Healthcare, Clinical Research Institute, Edgewood, KY
| | - Richard G Harm
- St. Elizabeth Healthcare, Clinical Research Institute, Edgewood, KY
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Novel Application of Exhaled Carbon Monoxide Monitors: Smoking Cessation in Orthopaedic Trauma Patients. J Orthop Trauma 2019; 33:e433-e438. [PMID: 31634289 DOI: 10.1097/bot.0000000000001558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether an in-office exhaled carbon monoxide (CO) monitor can increase interest in smoking cessation among the orthopaedic trauma population. DESIGN Prospective. SETTING Level I trauma center. PATIENTS One hundred twenty-four orthopaedic trauma patients. INTERVENTION In-office measurement of exhaled CO. MAIN OUTCOME MEASURES Stage of change, Likert scale score on willingness to quit today, patient's request for referral to a quitline, and increase in readiness to quit. RESULTS The use of an exhaled CO monitor increased willingness to quit in 71% of participants still smoking and increased willingness to quit on average by 0.8 points on a 10-point Likert scale (P < 0.001). Fifteen percent of patients modified their stage of change toward quitting. Forty percent of patients after exhaled CO monitor requested referral to a quitline, compared with 4% presurvey (P < 0.001). Anecdotally, most participants were very interested in the monitoring device and its reading, expressing concern with the result. The value of exhaled CO was not associated with any measured outcomes. CONCLUSIONS The use of an exhaled CO monitor increased willingness to quit smoking in 71% of patients, but the effect size was relatively small (0.8 points on a 10-point Likert scale). However, use of the CO monitor resulted in a large increase (40% vs. 4%) in referral to the national Quitline. Use of the Quitline typically increases the chance of smoking cessation by 10 times the baseline rate, suggesting that this finding might be clinically important. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Surgeon Mean Operative Times in Total Knee Arthroplasty in a Variety of Settings in a Health System. J Arthroplasty 2019; 34:2569-2572. [PMID: 31301911 DOI: 10.1016/j.arth.2019.06.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/23/2019] [Accepted: 06/10/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND High-quality care is essential in total joint arthroplasty. Multiple initiatives such as centers of excellence, patient optimization, and alternative payment models have demonstrated improved outcomes and decreased cost. Many studies have shown that longer operative times (OTs) are associated with increased frequency of postoperative complications. These findings often come from large data sets and may not accurately represent the average OT of individual surgeons. The purpose of this study was to determine the hospital and patient-related factors that influence OT. METHODS This retrospective study reviewed OT of 6003 total knee arthroplasty cases performed by 41 surgeons at 4 hospitals in a single health-care system. Mean OT was calculated for each surgeon. The effect of surgeon, hospital-, and patient-related factors on OT was assessed. RESULTS Among the 41 surgeons, the mean OT was 105 ± 25 minutes. Two community hospitals had significantly faster OT compared with the tertiary care academic hospital. Surgeons' OT for morbidly obese patients was significantly longer compared with normal, overweight, and obese patients. Surgeon volume, surgeon experience, trainee presence, and American Society of Anesthesiologists status did not significantly affect surgical time. CONCLUSIONS Operative time was influenced by hospital-related (tertiary, community) and patient-related (morbid obesity vs lower body mass index groups) factors. However, specific surgeon factors (surgical volume, experience), surgical team factors (presence or absence of trainee), and patient factors (American Society of Anesthesiologists status) did not significantly alter the OT. Additional studies of larger health systems are needed to examine additional patient, surgeon, and hospital factors which may influence the OT.
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Fuhrmann A, Batash R, Schwarzkopf R, Backstein D. Patient willingness to contribute to the cost of novel implants in total joint arthroplasty: the Canadian experience. Can J Surg 2019; 62:294-299. [PMID: 31550090 DOI: 10.1503/cjs.007118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background In Canada, health care is covered by provincial health insurance programs; patients do not directly participate in paying for their acute care expenses. The aim of this study is to assess the willingness of Canadian patients to contribute to the costs of novel total joint arthroplasty implants. Methods We administered a questionnaire to patients attending an outpatient arthroplasty clinic in Ontario. In the questionnaire, the longevity and risk of complications of a “standard” implant were described. We asked if participants would be willing to contribute to the cost of 3 novel implants that had differing longevities and risks of complications compared with the standard implant. Results One hundred and fifteen patients completed our questionnaire. Up to 62% of patients were willing to contribute a copayment to get an implant with greater longevity. Willingness to pay decreased to 40% for an implant with greater longevity but an increased risk of complications. Forty percent of participants were willing to pay for an implant with the same longevity as the standard implant but a decreased risk of complications. Participants with a higher income were more willing than other participants to contribute to the cost of a novel implant with greater longevity or lower complication rates. Conclusion This study demonstrated that up to 62% of our sample of patients in Ontario were willing to share the costs of a novel total joint replacement implant. Willingness to pay was associated with the proposed benefits of the implant and certain patient characteristics. Our study shows that a high proportion of Canadian patients may be willing to copay to have access to new technologies.
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Affiliation(s)
- Ariel Fuhrmann
- From the Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ont. (Fuhrmann, Backstein); the Department of Orthopedic Surgery, Barzilai Medical Centre, Ashkelon, Israel (Fuhrmann, Batash); and the Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, N.Y. (Schwarzkopf)
| | - Ron Batash
- From the Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ont. (Fuhrmann, Backstein); the Department of Orthopedic Surgery, Barzilai Medical Centre, Ashkelon, Israel (Fuhrmann, Batash); and the Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, N.Y. (Schwarzkopf)
| | - Ran Schwarzkopf
- From the Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ont. (Fuhrmann, Backstein); the Department of Orthopedic Surgery, Barzilai Medical Centre, Ashkelon, Israel (Fuhrmann, Batash); and the Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, N.Y. (Schwarzkopf)
| | - David Backstein
- From the Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ont. (Fuhrmann, Backstein); the Department of Orthopedic Surgery, Barzilai Medical Centre, Ashkelon, Israel (Fuhrmann, Batash); and the Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, N.Y. (Schwarzkopf)
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He Y, Xiao J, Shi Z, He J, Li T. Supplementation of enteral nutritional powder decreases surgical site infection, prosthetic joint infection, and readmission after hip arthroplasty in geriatric femoral neck fracture with hypoalbuminemia. J Orthop Surg Res 2019; 14:292. [PMID: 31481078 PMCID: PMC6724262 DOI: 10.1186/s13018-019-1343-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/22/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Nearly half of elderly patients with hip fracture were malnourished, indicated with a serum marker of hypoalbuminemia. Malnutrition was a risk factor for poor outcomes in geriatrics after hip replacement. The purpose of this study was to investigate if oral nutritional supplementation after the procedure in geriatrics with hypoalbuminemia was beneficial for outcomes. METHODS A retrospective cohort study of older (≥ 65 years old) patients suffering femoral neck fracture and undergoing hip replacement with hypoalbuminemia was conducted. Outcomes were compared between patients with and without postoperative nutritional supplementation. RESULTS There were 306 geriatric patients met the criteria. Following adjustment for baseline characteristics, patients with nutritional supplementation showed a lower grade of wound effusion with adjusted OR 0.57 (95% confidence interval (CI), 0.36 to 0.91, P < 0.05). And also a lower rate of surgical site infection (5.5% compared with 13.0% [adjusted OR 0.40, 95% CI, 0.17 to 0.91, P < 0.05]), periprosthetic joint infection (2.8% compared with 9.9% [adjusted OR 0.26, 95% CI, 0.08 to 0.79, P < 0.05]), and 30 days readmission (2.1% compared with 8.7% [adjusted OR 0.22, 95% CI, 0.06 to 0.79, P < 0.05]). The average total hospital stay was longer in patients without nutritional supplementation (10.7 ± 2.0 compared with 9.2 ± 1.8 days, P < 0.05). CONCLUSIONS The data suggest that postoperative nutritional supplementation is a protective factor for surgical site infection, periprosthetic joint infection, and 30-days readmission in geriatric with hypoalbuminemia undergoing a hip replacement. Postoperative nutritional supplementation for these patients should be recommended.
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Affiliation(s)
- Yaoquan He
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jun Xiao
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zhanjun Shi
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jinwen He
- Department of Rehabilitation, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Tao Li
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
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Preoperative Optimization Checklists Within the Comprehensive Care for Joint Replacement Bundle Have Not Decreased Hospital Returns for Total Knee Arthroplasty. J Arthroplasty 2019; 34:S108-S113. [PMID: 30611521 DOI: 10.1016/j.arth.2018.12.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Comprehensive Care for Joint Replacement (CJR) model has resulted in the evolution of preoperative optimization programs to decrease costs and hospital returns. At the investigating institution, one center was not within the CJR bundle and has dedicated fewer resources to this effort. The remaining centers have adopted an 11 metric checklist designed to identify and mitigate modifiable preoperative risks. We hypothesized that this checklist would improve postoperative metrics that impact costs for total knee arthroplasty (TKA) patients eligible for participation in CJR. METHODS Patients undergoing TKA from 2014 to 2018 were retrospectively reviewed. Only patients with eligible participation in CJR were included. Outcome variables including length of stay, disposition, 90-day emergency department visits, and hospital readmissions were explored. Analysis was performed to determine differences in outcomes between CJR participating and non-CJR participating hospitals within the healthcare system. RESULTS In total, 2308 TKA patients including 1564 from a CJR participating center and 744 from a non-CJR center were analyzed. There was no significant difference in patient age or gender. Patients at the non-CJR hospital had significantly higher body mass index (P < .001) and American Society of Anesthesiologists scores (P < .001), while those in the CJR network had fewer skilled nursing facility discharges (P = .028) and shorter length of stay (P < .001). However, there was no reduction in 90-day emergency department visits or readmissions. CONCLUSION The resources utilized at CJR participating hospitals, including patient optimization checklists, did not effectively alter patient outcomes following discharge. Likely, a checklist alone is insufficient for risk mitigation and detailed optimization protocols for modifiable risk factors must be investigated.
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Tobacco use results in inferior outcomes after anatomic total shoulder arthroplasty. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Despite the development of newer preventative measures, the rate of infection continues to be approximately 1% for patients undergoing total joint arthroplasty (TJA). The extent of the infection can range from a mild superficial infection to a more serious periprosthetic joint infection (PJI). PJIs not only play a significant role in the clinical well-being of the TJA patient population, but also have substantial economic implications on the health care system. Several approaches are currently being used to mitigate the risk of PJI after TJA. The variety of prophylactic measures to prevent infection after TJA must be thoroughly discussed and evaluated.
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Rhee C, Lethbridge L, Richardson G, Dunbar M. Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3 months and 1 year after primary total hip or knee arthroplasty. Can J Surg 2018; 61:165-176. [PMID: 29806814 DOI: 10.1503/cjs.007117] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Total joint replacement (TJR) is increasingly performed in older patients with more comorbidities, who are considered at higher risk for postoperative complications. We aimed to identify and calculate the odds ratio of the risk factors for infection, revision and death 3 months and 1 year after TJR as well as for postoperative blood transfusion and longer hospital stay. METHODS We analyzed all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases in Nova Scotia between Apr. 1, 2000, and Mar. 31, 2014, as identified from the Discharge Abstract Database. We used the Charlson Comorbidity Index as a surrogate measure of comorbidities. We used hospital and physician billings data and Nova Scotia Vital Statistics data to identify the postoperative events in this cohort. RESULTS A total of 10 123 primary THA and 17 243 primary TKA procedures were performed during the study period. The mean patient age was 66.1 (standard deviation 11.7) years and 67.1 (standard deviation 9.3) years, respectively. With THA, the risk of infection was higher in patients with heart failure and those with diabetes. For TKA, liver disease and blood transfusion were associated with a higher risk of infection. Revision rates were higher among patients with hypertension and those with paraparesis/hemiparesis for THA, and among patients with metastatic disease for TKA. Significant risk factors for death included metastatic disease, older age, heart failure, myocardial infarction, dementia, rheumatologic disease, renal disease, blood transfusion and cancer. Multiple medical comorbidities and older age were associated with higher rates of blood transfusion and longer hospital stay. CONCLUSION We have identified the risk factors associated with higher rates of postoperative complications and longer hospital stay after TJR. The results enable individualized risk stratification during the preoperative consultation.
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Affiliation(s)
- Chanseok Rhee
- From the Department of Surgery, Dalhousie University, Halifax, NS (Rhee, Lethbridge, Richardson, Dunbar)
| | - Lynn Lethbridge
- From the Department of Surgery, Dalhousie University, Halifax, NS (Rhee, Lethbridge, Richardson, Dunbar)
| | - Glen Richardson
- From the Department of Surgery, Dalhousie University, Halifax, NS (Rhee, Lethbridge, Richardson, Dunbar)
| | - Michael Dunbar
- From the Department of Surgery, Dalhousie University, Halifax, NS (Rhee, Lethbridge, Richardson, Dunbar)
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Eligibility Criteria for Lower Extremity Joint Replacement May Worsen Racial and Socioeconomic Disparities. Clin Orthop Relat Res 2018; 476:2301-2308. [PMID: 30303879 PMCID: PMC6259890 DOI: 10.1097/corr.0000000000000511] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cost-containment strategies may discourage hospitals from performing surgery for patients with preexisting risk factors such as those with high body mass index (BMI), those with high hemoglobin A1c (HbA1c), or those who smoke cigarettes. Because these risk factors may not appear in equal proportions across the population, using these risk factors as inflexible eligibility criteria for lower extremity joint arthroplasty may exacerbate existing racial-ethnic, gender, and socioeconomic disparities pertaining to access to an operation that can improve health and quality of life. However, any effects on such disparities have not yet been quantified nor have the groups been identified that may be most affected by inflexible eligibility criteria. QUESTIONS/PURPOSES Does the use of inflexible eligibility criteria related to (1) BMI; (2) HbA1c level; and (3) smoking status potentially decrease the odds of lower extremity joint arthroplasty eligibility for members of racial-ethnic minority groups, women, and those of lower socioeconomic status more than it does for non-Hispanic whites, men, and those of higher socioeconomic status? METHODS We pooled data from 21,294 adults aged ≥ 50 years from the 1999-2014 National Health and Nutrition Examination Survey (NHANES). NHANES is a nationally administered series of surveys that assess the health and nutritional status of the US population and collect information on many risk factors for diseases. NHANES is uniquely suited to examine our study questions because it includes data from physical examinations and laboratory assessments as well as comprehensive questionnaires, and it is nationally representative. We determined the odds of lower extremity arthroplasty eligibility by running separate multivariable logistic regressions for each criterion (that is, for each dependent variable): (1) BMI < 35 kg/m; (2) BMI < 40 kg/m; (3) HbA1c < 8%; and (4) current nonsmoker status. Independent variables of interest were race-ethnicity, gender, educational level, and annual household income. Each model included all independent variables of interest, age, and survey year. RESULTS The BMI < 35-kg/m criterion resulted in lower arthroplasty eligibility for non-Hispanic blacks compared with non-Hispanic whites (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.55-0.70; p < 0.001), women versus men (OR, 0.61; 95% CI, 0.55-0.69; p < 0.001), individuals of lower socioeconomic status versus those of higher socioeconomic status (annual household income < USD 45,000 versus ≥ USD 45,000 [OR, 0.81; 95% CI, 0.71-0.93; p = 0.002], and those with a high school degree or less versus those with a degree beyond a high school degree (OR, 0.66; 95% CI, 0.57-0.77; p < 0.001). The HbA1c < 8% criterion resulted in lower arthroplasty eligibility for non-Hispanic blacks (OR, 0.44; 95% CI, 0.37-0.53; p < 0.001) and Hispanics (OR, 0.41; 95% CI, 0.33-0.51; p < 0.001) versus non-Hispanic whites, for individuals of lower socioeconomic status versus those of higher socioeconomic status (OR, 0.73; 95% CI, 0.56-0.94; p = 0.015), and for those with a high school degree or less versus those with a degree beyond a high school degree (OR, 0.58; 95% CI, 0.44-0.77; p < 0.001). Excluding smokers resulted in lower arthroplasty eligibility for non-Hispanic blacks versus non-Hispanic whites (OR, 0.84; 95% CI, 0.73-0.97; p = 0.019), for individuals of lower socioeconomic status versus those of higher socioeconomic status (OR, 0.53; 95% CI, 0.47-0.61; p < 0.001), and for those with a high school degree or less versus those with a degree beyond a high school degree (OR, 0.29; 95% CI, 0.24-0.35; p < 0.001). CONCLUSIONS Payment structures and clinical decision-making algorithms that set inflexible cutoffs with respect to BMI, HbA1c, and smoking status disproportionately discourage performing lower extremity arthroplasty for non-Hispanic blacks and individuals of lower socioeconomic status. We do not advocate performing elective surgery for patients with multiple, uncontrolled medical comorbidities. However, ample evidence suggests that many patients whose BMI values are > 35 kg/m (or even > 40 kg/m) may be reasonable candidates for arthroplasty surgery, and BMI is not an easily modifiable risk factor for many patients. We discourage across-the-board cutoff parameters in these domains because such cutoffs will worsen current racial-ethnic, gender-based, and socioeconomic disparities and limit access to an operation that can improve quality of life. LEVEL OF EVIDENCE Level III, economic and decision analysis.
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Internal Validation of a Predictive Model for Complications After Total Hip Arthroplasty. J Arthroplasty 2018; 33:3759-3767. [PMID: 30193881 DOI: 10.1016/j.arth.2018.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/21/2018] [Accepted: 08/08/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) is projected to increase in prevalence and associated complications will impose significant cost on the US healthcare system. The purpose of this study is to validate a predictive model for postoperative complications utilizing a novel 11-component hip-specific questionnaire encompassing preoperatively available clinical and radiographic data. METHODS Consecutive primary THA patients between January 2014 and January 2016 were included. Exclusion criteria included patients without questionnaire scoring variables and less than 1-year follow-up. Patients were stratified into 4 tiers based on their questionnaire score: low risk (>74), mild risk (57-73), moderate risk (41-56), and high risk (<40). A binary logistic regression was performed to determine if the questionnaire predicted complications. Receiver-operator curves were constructed to determine the threshold score below which there was a high likelihood of experiencing a complication. RESULTS Four hundred fifty patients were included in the final analysis with a mean (range) follow-up of 2.1 years (1.0-5.9), age of 63.1 years (25.7-9.17), and body mass index of 31.7 kg/m2 (17.8-64.5). The complication rate was 13.6%. A hip questionnaire score of 73.8 conferred a 98.5% sensitivity and 98.5% negative predictive value for complications. The questionnaire score was the strongest predictor of a decreased complication likelihood (odds ratio 0.94, 95% confidence interval 0.90-0.97, P < .001). Risk tier was significantly associated with complications (low risk: 0; mild risk: 12; moderate risk: 25; and high risk: 24; P < .001). CONCLUSION This novel hip questionnaire demonstrated a high sensitivity and negative predictive value to identify patients at risk for postoperative complications. Future studies should attempt to prospectively validate the use of this questionnaire.
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Civinini R, Cozzi Lepri A, Carulli C, Matassi F, Villano M, Innocenti M. The anterior-based muscle-sparing approach to the hip: the "other" anterior approach to the hip. INTERNATIONAL ORTHOPAEDICS 2018; 43:47-53. [PMID: 30284607 DOI: 10.1007/s00264-018-4190-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/26/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE The purpose of this study was to evaluate safety, efficacy, and learning curves of anterior-based muscle-sparing total hip arthroplasty (ABMS-THA) in the supine position. Furthermore, early functional outcome was evaluated and compared to direct anterior approach (DAA) by measuring surface electromyography (sEMG). METHODS We present a prospective cohort study of 343 hips. The safety and learning curve were assessed by recording operative time and peri-operative adverse events. For assessment of efficacy, functional and radiological outcomes were evaluated. A selected group of 32 patients have been studied by sEMG and compared to a matched group of 32 patients who received a THA using DAA approach. RESULTS There was one dislocation (0.3%); two (0.6%) patients had an intra-operative fractures of the greater trochanter; two patients (0.6%) experienced a self-limited femoral nerve palsy. Physical therapy milestones for hospital discharge were reached on an average of 1.7 days. sEMG showed that ABMS and DAA have a similar muscle recruitment pattern and functional recovery after THA. One patient was revised for infection, 16 were lost, and 326 hips were available with a median follow-up of 42 months (range 24-60). The mean Harris Hip Score (HSS) increased from 44.3 to 91.9. Ninety-six percent of the hips had a leg length discrepancy (LLD) < 5 mm. There were no radiological signs of mechanical loosening or osteolysis. CONCLUSIONS The ABMS approach in the supine position is clinically effective and safe; special advantages include a very low dislocation rate and a great control of LLD.
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Affiliation(s)
- Roberto Civinini
- Orthopaedic Clinic, Department of Surgery and Translational Medicine, University of Florence, C.T.O. Largo Palagi 1, 50139, Florence, Italy.
| | - Andrea Cozzi Lepri
- Orthopaedic Clinic, Department of Surgery and Translational Medicine, University of Florence, C.T.O. Largo Palagi 1, 50139, Florence, Italy
| | - Christian Carulli
- Orthopaedic Clinic, Department of Surgery and Translational Medicine, University of Florence, C.T.O. Largo Palagi 1, 50139, Florence, Italy
| | - Fabrizio Matassi
- Orthopaedic Clinic, Department of Surgery and Translational Medicine, University of Florence, C.T.O. Largo Palagi 1, 50139, Florence, Italy
| | - Marco Villano
- Orthopaedic Clinic, Department of Surgery and Translational Medicine, University of Florence, C.T.O. Largo Palagi 1, 50139, Florence, Italy
| | - Massimo Innocenti
- Orthopaedic Clinic, Department of Surgery and Translational Medicine, University of Florence, C.T.O. Largo Palagi 1, 50139, Florence, Italy
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Feng JE, Novikov D, Anoushiravani AA, Wasterlain AS, Lofton HF, Oswald W, Nazemzadeh M, Weiser S, Berger JS, Iorio R. Team Approach: Perioperative Optimization for Total Joint Arthroplasty. JBJS Rev 2018; 6:e4. [DOI: 10.2106/jbjs.rvw.17.00147] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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DiNubile N. Glucosamine and Chondroitin Sulfate: What Has Been Learned Since the Glucosamine/chondroitin Arthritis Intervention Trial. Orthopedics 2018; 41:200-207. [PMID: 29771395 DOI: 10.3928/01477447-20180511-06] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/13/2017] [Indexed: 02/03/2023]
Abstract
Glucosamine and chondroitin sulfate, alone or in combination, are used worldwide by individuals suffering from osteoarthritis pain. They are by prescription in some countries but are available as over-the-counter dietary supplements in other countries, such as the United States. The inconclusive results of the National Institutes of Health-sponsored Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) did little to clarify the efficacy of these agents. However, some newer studies have provided a better perspective on the potential benefits that they can offer. Because the 2 in combination showed a significant level of efficacy in the moderate-to-severe knee osteoarthritis subgroup of the GAIT, this review examines the randomized, controlled trials published from that time to the present. The findings of these studies are mixed, owing in some cases to the high rate of placebo response added to by the ethical incorporation of rescue analgesics into protocols designed to evaluate the slow-acting, subtle effects of glucosamine and chondroitin sulfate in combination. The strong influence of the placebo effect and confounding of results by rescue analgesics point to the importance of objective measurement tools such as osteoarthritis biomarker panels in long-term glucosamine/chondroitin sulfate clinical trials with less reliance on the subjective measurement tools commonly used in osteoarthritis trials of pharmaceuticals. [Orthopedics. 2018; 41(4):200-207.].
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Gray CF, Prieto HA, Duncan AT, Parvataneni HK. Arthroplasty care redesign related to the Comprehensive Care for Joint Replacement model: results at a tertiary academic medical center. Arthroplast Today 2018; 4:221-226. [PMID: 29896557 PMCID: PMC5994641 DOI: 10.1016/j.artd.2018.02.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/31/2018] [Accepted: 02/04/2018] [Indexed: 12/21/2022] Open
Abstract
Background Total joint arthroplasty (TJA) remains the highest expenditure in the Centers for Medicare and Medicaid Services (CMS) budget. One model to control cost is the Comprehensive Care for Joint Replacement (CJR) model. There has been no published literature to date examining the efficacy of CJR on value-based outcomes. The purpose of this study was to determine the efficacy and sustainability of a multidisciplinary care redesign for total joint arthroplasty under the CJR paradigm at an academic tertiary care center. Methods We implemented a system-wide care redesign, affecting all patients who underwent a total hip or total knee arthroplasty at our academic medical center. The main study outcomes were cost (to CMS), discharge destination, complications and readmissions, and length of stay (LOS); these were measured using the 2017 initial CJR reconciliation report, as well as our institutional database. Results The study included 1536 patients (41% Medicare). Per-episode cost to CMS declined by 19.5% to 11% below the CMS-designated national target. Home discharge increased from 62% to 87%. CMS readmissions declined from 15% to 6%; major complications decreased from 2.3% to 1.9%; and LOS declined from 3.6 to 2.1 days. Conclusions A mandatory episode-based bundled-payment program can induce favorable changes to value-based metrics, improving quality and outcomes for health-care consumers. Quality and value were improved in this study, evidenced by lower 90-day episode cost, more home discharges, lower readmissions and complications, and shorter LOS. This approach has implications not just for CMS, but for private payers, corporate health programs, and fixed-budget health-care models.
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Affiliation(s)
- Chancellor F Gray
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Hernan A Prieto
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Andrew T Duncan
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Hari K Parvataneni
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
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Yu S, Dundon J, Solovyova O, Bosco J, Iorio R. Can Multimodal Pain Management in TKA Eliminate Patient-controlled Analgesia and Femoral Nerve Blocks? Clin Orthop Relat Res 2018; 476. [PMID: 29529623 PMCID: PMC5919240 DOI: 10.1007/s11999.0000000000000018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND TKA pain management protocols vary widely with no current consensus on a standardized pain management regimen. Multimodal TKA pain management protocols aim to address pain control, facilitate functional recovery, and maintain patient satisfaction. QUESTIONS/PURPOSES (1) Did changes to our pain management protocol, specifically adding liposomal bupivacaine, eliminating patient-controlled analgesia (PCA), and discontinuing femoral nerve blocks (FNBs), affect narcotic consumption after TKA? (2) Did these changes to our pain management protocols affect patient-reported pain scores? (3) Does the use of an immediate postoperative PCA affect rapid rehabilitation and functional recovery? (4) How did changes to our pain management regimen affect discharge disposition and pain-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores? METHODS We retrospectively analyzed an institutional arthroplasty database between September 2013 and September 2015 containing 1808 patients who underwent primary TKA. Departmental pain management protocols were compared in 6-month periods as the protocol changed. All patients received a multimodal pain management protocol including preoperative oral medications, spinal or general anesthesia, a short-acting intraoperative pericapsular injection, and continued postoperative oral narcotics for breakthrough pain. From September 2013 to April 2014, all patients received an intraoperative FNB and a PCA for the first 24 hours postoperatively (Cohort 1). From May 2014 to October 2014, a periarticular injection of liposomal bupivacaine was added to the protocol and FNBs were discontinued (Cohort 2). After April 2015, PCA was eliminated (Cohort 3). No other major changes were made to the TKA pain management pathways. Narcotic use, pain scores on 8-hour intervals, physical therapy milestones, and discharge disposition were compared. RESULTS Total narcotic use was the least in Cohort 3 (Cohort 3: 66 ± 54 morphine milligram equivalents versus Cohort 2: 82 ± 72 versus Cohort 1: 96 ± 62; p < 0.001). There was an increase in pain score immediately after surgery in Cohort 3 (4.0 ± 3.5 versus 1.2 ± 2.2 versus 1.2 ± 2.5, post hoc analysis of Cohort 2 versus 3: mean difference 2.6, 95% confidence interval [CI] 2.2-3.0; p < 0.001); however, it was not different for the remainder of the hospital stay. Patients who did not receive PCA reached functional milestones for both gait and stairs faster by postoperative day 1 (47% [328 of 698] versus 30% [158 of 527] versus 16% [93 of 583], p < 0.001; Cohort 3 versus 2: odds ratio 2.1, 95% CI 1.6-2.6; p < 0.001). Discharge to home occurred more frequently (84% [583 of 698] versus 78% [410 of 527] versus 72% [421 of 583], p = 0.010) in Cohort 3. There were no differences in pain-related HCAHPS scores across all cohorts. CONCLUSIONS Discontinuing PCAs and FNBs from our multimodal TKA pain management protocols and adding liposomal bupivacaine resulted in fewer narcotics consumed with no difference in pain control and faster functional recovery while maintaining high HCAHPS scores relating to pain. LEVEL OF EVIDENCE Level III, therapeutic study.
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MESH Headings
- Analgesia, Patient-Controlled/adverse effects
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/adverse effects
- Arthralgia/diagnosis
- Arthralgia/etiology
- Arthralgia/physiopathology
- Arthralgia/prevention & control
- Arthroplasty, Replacement, Knee/adverse effects
- Bupivacaine/administration & dosage
- Bupivacaine/adverse effects
- Combined Modality Therapy
- Databases, Factual
- Femoral Nerve
- Humans
- Knee Joint/innervation
- Knee Joint/surgery
- Liposomes
- Nerve Block/adverse effects
- Nerve Block/methods
- Pain Management/adverse effects
- Pain Management/methods
- Pain Measurement
- Pain, Postoperative/diagnosis
- Pain, Postoperative/genetics
- Pain, Postoperative/physiopathology
- Pain, Postoperative/prevention & control
- Patient Reported Outcome Measures
- Patient Satisfaction
- Recovery of Function
- Retrospective Studies
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Stephen Yu
- NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, USA
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Sahota S, Lovecchio F, Harold RE, Beal MD, Manning DW. The Effect of Smoking on Thirty-Day Postoperative Complications After Total Joint Arthroplasty: A Propensity Score-Matched Analysis. J Arthroplasty 2018; 33:30-35. [PMID: 28870742 DOI: 10.1016/j.arth.2017.07.037] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/20/2017] [Accepted: 07/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) is a highly successful treatment, but is burdensome to the national healthcare budget. National quality initiatives seek to reduce costly complications. Smoking's role in perioperative complication after TJA is less well known. This study aims to identify smoking's independent contribution to the risk of short-term complication after TJA. METHODS All patients undergoing primary TJA between 2011 and 2012 were selected from the American College of Surgeon's National Surgical Quality Improvement Program's database. Outcomes of interest included rates of readmission, reoperation, mortality, surgical complications, and medical complications. To eliminate confounders between smokers and nonsmokers, a propensity score was used to generate a 1:1 match between groups. RESULTS A total of 1251 smokers undergoing TJA met inclusion criteria. Smokers in the combined total hip and knee arthroplasty cohort had higher 30-day readmission (4.8% vs 3.2%, P = .041), were more likely to have a surgical complication (odds ratio 1.84, 95% confidence interval 1.21-2.80), and had a higher rate of deep surgical site infection (SSI) (1.1% vs 0.2%, P = .007). Analysis of total hip arthroplasty only revealed that smokers had higher rates of deep SSI (1.3% vs 0.2%, P = .038) and higher readmission rate (4.3% vs 2.2%, P = .034). Analysis of total knee arthroplasty only revealed greater surgical complications (2.8% vs 1.2%, P = .048) and superficial SSI (1.8% vs 0.2%, P = .002) in smokers. CONCLUSION Smoking in TJA is associated with higher rates of SSI, surgical complications, and readmission.
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Affiliation(s)
- Shawn Sahota
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Francis Lovecchio
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ryan E Harold
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew D Beal
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David W Manning
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Sveom DS, Otteman MK, Garvin KL. Improving Quality and Decreasing Cost by Reducing Re-admissions in Patients Undergoing Total Joint Arthroplasty. Curr Rev Musculoskelet Med 2017; 10:388-396. [PMID: 28755149 PMCID: PMC5577425 DOI: 10.1007/s12178-017-9424-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Total joint arthroplasty (TJA) has had an increased demand over the recent years. It is a successful procedure, and there are relatively few complications, but there is a high overall cost. There is a push to increase the quality of care, lessen complications, and decrease cost by reducing readmissions. This article will discuss the risk factors that can contribute to the complication and readmission rates following TJA. RECENT FINDINGS Several risk factors have been found to contribute to the complication and readmission rates following a TJA. It is important to understand these risk factors and mitigate them as much as possible in order to optimize the patient experience. There are risk factors that cannot be modified, and the treatment team as well as the patient should be made aware of these and account for them when making the decision whether to undergo elective primary TJA or not. In general, an increased number of risk factors is associated with increased complications and increased readmission rates. At our institution, we have used this knowledge to improve our outcomes and decrease costs. It is important to be mindful of risk factors for poor outcomes prior to performing TJA. This allows for the optimization of patients prior to undergoing surgery. This can lead to improved outcomes at a lower cost.
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Affiliation(s)
- Daniel S. Sveom
- Department of Orthopaedic Surgery and Rehabilitation, 985640 Nebraska Medical Center, Omaha, NE 68198-5640 USA
| | - Mary K. Otteman
- Department of Orthopaedic Surgery and Rehabilitation, 985640 Nebraska Medical Center, Omaha, NE 68198-5640 USA
| | - Kevin L. Garvin
- Department of Orthopaedic Surgery and Rehabilitation, 985640 Nebraska Medical Center, Omaha, NE 68198-5640 USA
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Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital. J Arthroplasty 2017; 32:1739-1746. [PMID: 28153458 DOI: 10.1016/j.arth.2016.12.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 12/11/2016] [Accepted: 12/19/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model. METHODS Using a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013. RESULTS In total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period. CONCLUSION Increasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission.
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Liu P, Liu J, Xia K, Chen L, Wu X. Clinical Outcome Evaluation of Primary Total Knee Arthroplasty in Patients with Diabetes Mellitus. Med Sci Monit 2017; 23:2198-2202. [PMID: 28484205 PMCID: PMC5436413 DOI: 10.12659/msm.901720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background The aim of this study was to evaluate the safety and clinical outcome of primary total knee arthroplasty in patients with diabetes mellitus. Material/Methods Among the patients who were treated with total knee arthroplasty, there were 98 patients (116 knees) associated with diabetes. Osteoarthritis was diagnosed in 90 patients and rheumatoid arthritis was diagnosed in 8 patients. Various degrees of preoperative knee deformities were found in 82 knees. The average fasting blood glucose was 9.8±3.6 mmol/L at admission. Results The clinical efficacy of TKA was satisfactory in patients with diabetes mellitus. Diabetic patients do not seem to have a significantly higher risk for infection and DVT after TKA. At the final follow-up time point, no prosthesis loosening was found and no revision was needed in any patients. The mean HSS scores increased and the excellent rate was 100%. Conclusions Using perioperative comprehensive assessment of heart and lung function, and by preventing infection and the formation of DVT, we achieved satisfactory early clinical efficacy of TKA in patients with diabetes mellitus.
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Affiliation(s)
- Pengcheng Liu
- Department of Orthopedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China (mainland)
| | - Junfeng Liu
- Department of Orthopedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China (mainland)
| | - Kuo Xia
- Department of Orthopedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China (mainland)
| | - Liyang Chen
- Department of Orthopedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China (mainland)
| | - Xing Wu
- Department of Orthopedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China (mainland)
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Weinberg DS, Kraay MJ, Fitzgerald SJ, Sidagam V, Wera GD. Are Readmissions After THA Preventable? Clin Orthop Relat Res 2017; 475:1414-1423. [PMID: 27837400 PMCID: PMC5384913 DOI: 10.1007/s11999-016-5156-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/31/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Readmissions after total joint arthroplasty have become a key quality measure in elective surgery in the United States. The Affordable Care Act includes the Hospital Readmission Reduction Program, which calls for reduced payments to hospitals with excessive readmissions. This policy uses a method to determine excess readmission ratios and calculate readmission payment adjustments to hospitals, however, it is unclear whether readmission rates are an effective quality metric. The reasons or conditions associated with readmission after elective THA have been well established but the extent to which readmissions can be prevented after THA remains unclear. QUESTIONS/PURPOSES (1) Are unplanned readmissions after THA associated with orthopaedic or medical causes? (2) Are these readmissions preventable? (3) When during the course of aftercare are orthopaedic versus medical readmissions more likely to occur? METHODS We retrospectively evaluated all 1096 elective THAs for osteoarthritis performed between January 1, 2011 and June 30, 2014 at a major academic medical center. Of those, 69 patients (6%) who met inclusion criteria were readmitted in our healthcare system within 90 days of discharge after the index procedure during the study period. Fifty patients were readmitted within 30 days of discharge after the index procedure (5%). We defined a readmission as any unplanned inpatient or observation status admission to the hospital spanning at least one midnight. A panel of physicians not involved in the care of these patients used available criteria and existing consensus guidelines to evaluate the medical records, radiographs, and operative reports to identify whether the underlying reason for readmission was orthopaedic versus medical. They subsequently were classified as either nonpreventable or potentially preventable readmissions, based on any care that may have occurred during the index hospitalization. To make such determinations, consensus specialty society guidelines were used whenever possible for each readmission diagnosis. RESULTS A total of 50 of 1096 patients (5% of those who underwent THA during the period in question) were readmitted within 30 days and 69 of 1096 (6%) were readmitted within 90 days of their index procedures. Thirty-one patients were readmitted for orthopaedic reasons (31/69; 45%) and 38 of 69 were readmitted for medical reasons (55%). Three readmissions (three of 69; 4%) were identified as potentially preventable. Of these potentially preventable readmissions, one was orthopaedic (hip dislocation) and two were medical. Thirty-day readmissions were more likely to be orthopaedic than 90-day readmissions (odds ratio, 4.06; 95% CI, 1.18-13.96; p = 0.026). CONCLUSIONS Using a panel of expert reviewers, available existing criteria, and consensus methodology, it appears only a small percentage of readmissions after THA are potentially preventable. Orthopaedic readmissions occur earlier during the postoperative course. Currently, existing policies and readmission penalties may not serve as valuable external quality metrics. The readmission rates in our study may represent the threshold for expected readmission rates after THA. Future studies should enroll larger numbers of patients and have independent review panels in efforts to refine criteria for what constitutes preventable readmissions. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Douglas S. Weinberg
- grid.67105.35Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Matthew J. Kraay
- grid.67105.35Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Steven J. Fitzgerald
- grid.67105.35Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Vasu Sidagam
- grid.67105.35Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Glenn D. Wera
- grid.411931.fMetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109 USA
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Adverse childhood experiences and their effect on the orthopaedic surgery patient. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Strategies to Prevent Periprosthetic Joint Infection After Total Knee Arthroplasty and Lessen the Risk of Readmission for the Patient. J Am Acad Orthop Surg 2017; 25 Suppl 1:S13-S16. [PMID: 27984342 DOI: 10.5435/jaaos-d-16-00635] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
There is yet to be a standardized total knee arthroplasty (TKA) surgical protocol that has been studied to a sufficient degree to offer evidence-based practices regarding infection and readmission prevention. Although high-level evidence is often sought to provide guidance concerning protocol- and process-level decisions, the literature is often confusing and nondefinitive in its conclusions and recommendations regarding periprosthetic joint infection and readmission prevention. Areas of study that require further investigation include the following: the role of patient optimization and preoperative mitigation of risk; perioperative antibiotics; operating room environment; blood management; operative techniques, implants, and infection prevention measures; wound care management; and post acute care. Patient-associated modifiable risk must be optimized to decrease poly joint infection rates after TKA. Protocol measures for TKA need to be standardized, and evidence-based practice measures need to be validated.
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Iorio R, Bosco J, Slover J, Sayeed Y, Zuckerman JD. Single Institution Early Experience with the Bundled Payments for Care Improvement Initiative. J Bone Joint Surg Am 2017; 99:e2. [PMID: 28060238 DOI: 10.2106/jbjs.16.00066] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle.For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.
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Affiliation(s)
- Richard Iorio
- 1Department of Orthopaedic Surgery, New York University Langone Medical Center, New York, NY
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Dundon JM, Bosco J, Slover J, Yu S, Sayeed Y, Iorio R. Improvement in Total Joint Replacement Quality Metrics: Year One Versus Year Three of the Bundled Payments for Care Improvement Initiative. J Bone Joint Surg Am 2016; 98:1949-1953. [PMID: 27926675 DOI: 10.2106/jbjs.16.00523] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In January 2013, a large, tertiary, urban academic medical center began participation in the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty, a program implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011. Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 were included. We participated in BPCI Model 2, by which an episode of care includes the inpatient and all post-acute care costs through 90 days following discharge. The goal for this initiative is to improve patient care and quality through a patient-centered approach with increased care coordination supported through payment innovation. METHODS Length of stay (LOS), readmissions, discharge disposition, and cost per episode of care were analyzed for year 3 compared with year 1 of the initiative. Multiple programs were implemented after the first year to improve performance metrics: a surgeon-directed preoperative risk-factor optimization program, enhanced care coordination and home services, a change in venous thromboembolic disease (VTED) prophylaxis to a risk-stratified protocol, infection-prevention measures, a continued emphasis on discharge to home rather than to an inpatient facility, and a quality-dependent gain-sharing program among surgeons. RESULTS There were 721 Medicare primary total joint arthroplasty patients in year 1 and 785 in year 3; their data were compared. The average hospital LOS decreased from 3.58 to 2.96 days. The rate of discharge to an inpatient facility decreased from 44% to 28%. The 30-day all-cause readmission rate decreased from 7% to 5%; the 60-day all-cause readmission rate decreased from 11% to 6%; and the 90-day all-cause readmission rate decreased from 13% to 8%. The average 90-day cost per episode decreased by 20%. CONCLUSIONS Mid-term results from the implementation of Medicare BPCI Model 2 for primary total joint arthroplasty demonstrated decreased LOS, decreased discharges to inpatient facilities, decreased readmissions, and decreased cost of the episode of care in year 3 compared with year 1, resulting in increased value to all stakeholders involved in this initiative and suggesting that continued improvement over initial gains is possible.
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Affiliation(s)
- John M Dundon
- 1Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
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Inneh IA, Clair AJ, Slover JD, Iorio R. Disparities in Discharge Destination After Lower Extremity Joint Arthroplasty: Analysis of 7924 Patients in an Urban Setting. J Arthroplasty 2016; 31:2700-2704. [PMID: 27378643 DOI: 10.1016/j.arth.2016.05.027] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/04/2016] [Accepted: 05/09/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Discharge destination is an important factor to consider to maximize care coordination and manage patient expectations after total joint arthroplasty (TJA). It also has significant impact on the cost-effectiveness of these procedures given the significant cost of post-acute inpatient care. Therefore, understanding factors that impact discharge destination after TJA is critical. METHODS An evaluation of socioeconomic, geographic, and racial/ethnic factors associated with discharge destination to either home or institution (ie, rehabilitation, skilled nursing facility, and so forth) following joint arthroplasty of the lower extremity was conducted. We analyzed data on patients admitted between 2011 and 2014 for primary or revision hip or knee arthroplasty at a single institution. Bivariate and multivariate statistical techniques were applied to determine associations. RESULTS Included in the analysis were 7924 cases of lower extremity joint procedures, of which 4836 (61%), 785 (10%), and 2770 (35%) were of female gender, low socioeconomic status, and nonwhite race/ethnicity, respectively. A total of 5088 (64%) and 2836 (36%) cases were discharged to home and institution, respectively. Significant predictors of discharge to an institution in the multivariate analysis include SES (low and middle SES [odds ratio {OR}: 1.27, 95% confidence interval {CI}: 1.02-1.57, P = .029; and OR: 1.26, 95% CI: 1.10-1.44, P = .001]), age (OR: 1.05, 95% CI: 1.049-1.060, P < .001), female gender (OR: 1.69, 95% CI: 1.52-1.89, P < .001) and TKA procedure (OR: 1.48, 95% CI: 1.33-1.64, P < .001). Patients of nonblack race/ethnicity were more likely to be discharged home (white OR: 0.84, 95% CI: 0.72-0.98, P = .027; other OR: 0.80, 95% CI: 0.67-0.95, P = .009). CONCLUSION Socioeconomic status and race/ethnicity are important factors related to discharge destination following TJA. Thoroughly understanding and addressing these factors may help increase the rates of discharge to home as opposed to institution.
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Affiliation(s)
- Ifeoma A Inneh
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York; Department of Public Health and Policy, School of Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Andrew J Clair
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - James D Slover
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
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Outpatient total shoulder arthroplasty: a population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty. J Shoulder Elbow Surg 2016; 25:1780-1786. [PMID: 27282739 DOI: 10.1016/j.jse.2016.04.006] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/31/2016] [Accepted: 04/05/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The rate of total shoulder arthroplasty (TSA) is rising, which has an impact on health care expenditure. One avenue to mitigate cost is outpatient TSA. There are currently no published reports of this practice. In this study, we determine the 30-day adverse event and readmission rates after outpatient TSA and compare these rates with inpatient TSA. METHODS A retrospective cohort study using a population database in the United States was undertaken. Patients who underwent primary TSA between 2005 and 2014 were identified and divided into 2 cohorts based on length of stay (LOS): outpatient TSA (LOS 0 days) and inpatient TSA (LOS >0 days). Patient and procedure characteristics were collected. The 30-day adverse event and readmission rates were calculated for each cohort. A multivariate logistic regression determined if the odds of an adverse event or readmission were significantly different between the inpatient and outpatient TSA cohorts. RESULTS Overall, 7197 patients in this database underwent TSA between 2005 and 2014, of which 173 patients (2.4%) underwent outpatient TSA. The 30-day adverse event rate in the outpatient and inpatient TSA cohorts was 2.31% and 7.89%, respectively. The 30-day readmission rate in the outpatient and inpatient TSA cohorts was 1.74% and 2.93%, respectively. In the multivariate logistic regression, the odds of an adverse event or readmission were not significantly different (odds ratio of 0.4 [P = .077] and odds ratio of 0.7 [P = .623], respectively). CONCLUSION There are no significant differences in the 30-day adverse event and readmission rates between outpatient and inpatient TSA. In the appropriately selected patient, outpatient TSA is safe and cost-effective.
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Edwards PK, Barnes CL. Dealing with the outliers—Physicians, inpatient post-acute care providers, physical therapists, and visiting nursing facilities. ACTA ACUST UNITED AC 2016. [DOI: 10.1053/j.sart.2016.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Smith TO, Aboelmagd T, Hing CB, MacGregor A. Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Bone Joint J 2016; 98-B:1160-6. [DOI: 10.1302/0301-620x.98b9.38024] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/10/2016] [Indexed: 12/17/2022]
Abstract
Aims Our aim was to determine whether, based on the current literature, bariatric surgery prior to total hip (THA) or total knee arthroplasty (TKA) reduces the complication rates and improves the outcome following arthroplasty in obese patients. Methods A systematic literature search was undertaken of published and unpublished databases on the 5 November 2015. All papers reporting studies comparing obese patients who had undergone bariatric surgery prior to arthroplasty, or not, were included. Each study was assessed using the Downs and Black appraisal tool. A meta-analysis of risk ratios (RR) and 95% confidence intervals (CI) was performed to determine the incidence of complications including wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), revision surgery and mortality. Results From 156 potential studies, five were considered to be eligible for inclusion in the study. A total of 23 348 patients (657 who had undergone bariatric surgery, 22 691 who had not) were analysed. The evidence-base was moderate in quality. There was no statistically significant difference in outcomes such as superficial wound infection (relative risk (RR) 1.88; 95% confidence interval (CI) 0.95 to 0.37), deep wound infection (RR 1.04; 95% CI 0.65 to 1.66), DVT (RR 0.57; 95% CI 0.13 to 2.44), PE (RR 0.51; 95% CI 0.03 to 8.26), revision surgery (RR 1.24; 95% CI 0.75 to 2.05) or mortality (RR 1.25; 95% CI 0.16 to 9.89) between the two groups. Conclusion For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are obese or morbidly obese. This finding is based on moderate quality evidence. Cite this article: Bone Joint J 2016;98-B:1160–6.
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Affiliation(s)
| | - T. Aboelmagd
- Norfolk and Norwich University Hospital, Norwich, UK
| | - C. B. Hing
- St George’s University Hospitals NHS Foundation
Trust, London, UK
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Anoushiravani AA, Iorio R. Alternative payment models: From bundled payments for care improvement and comprehensive care for joint replacement to the future? ACTA ACUST UNITED AC 2016. [DOI: 10.1053/j.sart.2016.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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