AB1465 BLACK PATIENTS ARE LESS SATISFIED WITH THE PROCESS OF CARE FOLLOWING PRIMARY HIP AND KNEE ARTHROPLASTY: A RETROSPECTIVE STUDY

Background

Patients’ post-operative satisfaction with their hospital experience is important to patient care, hospital reimbursement, and comparison between hospitals. The Press Ganey (PG) inpatient survey is commonly administered to assess patient satisfaction with the process of care. However, whether patient PG survey scores following primary unilateral hip and knee arthroplasty are associated with a patient’s race and socioeconomic status (SES) is unknown.

Objectives

We aimed to determine whether patient PG survey overall assessment scores differ by race and SES.

Methods

We linked data for patients in large institutional hip and knee arthroplasty registries consisting of surgeries from July 2010–February 2012 to their PG survey responses. Patients undergoing primary unilateral surgery of Black or White race who resided in New York, New Jersey, or Connecticut at the time of surgery were included in the analysis. The primary outcome variable was the PG overall assessment score, calculated as the mean of a patient’s ratings for the three questions in the “Overall Assessment” section of the PG survey and dichotomized as either completely satisfied (score of 100) or not completely satisfied (score <100). Primary payor was used as a proxy for patient SES. Multivariable logistic regression was performed for the hip and knee cohorts separately to determine if patient race and primary payor were associated with not being completely satisfied, adjusting for age, sex, and American Society of Anesthesiology (ASA) score.

Results

There were 2,516 hip patients and 2,113 knee patients with PG overall assessment scores included in the analyses (Table 1). Black patients were more likely to be not completely satisfied compared to White patients in both cohorts [hip (odds ratio (OR)=1.64; 95% confidence interval (CI): 1.03, 2.61; p=0.04)]; [knee (OR=1.83; 95% CI: 1.16, 2.88; p=0.01). In the hip cohort, patients between 70-79 years old (OR=1.71; 95% CI: 1.09, 2.67; p=0.02) and older than 80 years (OR=2.00; 95% CI: 1.20, 3.32; p<0.01) were more likely to be not completely satisfied. In the knee cohort, patients 50-59 years old (OR=0.56; 95% CI: 0.33, 0.97; p=0.04) and 60-69 years old (OR=0.57; 95% CI: 0.33, 0.96; p=0.03) were less likely to be not completely satisfied compared to patients <50 years old.

Table 1.

Likelihood of not being completely satisfied with the process of care (PG score <100)

VariableReferenceCategoryHip Cohort (n = 2,516)Knee Cohort (n = 2,113)Odds Ratio95% CIp-valueOdds Ratio95% CIp-valueAge Group<5050-591.02(0.69, 1.50)0.9390.56(0.32, 0.97)0.039<5060-691.04(0.70, 1.54)0.8580.57(0.33, 0.96)0.034<5070-791.71(1.09, 2.67)0.0190.63(0.36, 1.11)0.113<5080+2.00(1.20, 3.32)0.0080.97(0.53, 1.77)0.912SexFemaleMale0.84(0.69, 1.02)0.0821.03(0.83, 1.26)0.816RaceWhiteBlack1.64(1.03, 2.61)0.0381.83(1.16, 2.88)0.010ASA status121.04(0.70, 1.55)0.8321.23(0.60, 2.51)0.580131.45(0.91, 2.29)0.1161.36(0.64, 2.87)0.41914<0.01(0.00, ***)0.968<0.01(0.00, ***)0.977Primary PayorMedicareMedicaid1.35(0.26, 7.01)0.718<0.01(0.00, ***)0.983MedicareOther/Unknown1.24(0.94, 1.64)0.1260.87(0.65, 1.17)0.362MedicarePrivate1.13(0.61, 2.10)0.6881.01(0.57, 1.78)0.983

ASA = American Society of Anesthesiologist (ASA) physical status classification. PG = Press Ganey. CI = Confidence Interval. *** indicates >999.99. Bold indicates p < 0.05

Conclusion

Black patients were less likely to be completely satisfied compared to White patients following total hip and knee arthroplasty. More research is needed to investigate other factors such as perceived staff courtesy and baseline pain and function to understand why these disparities exist.

Acknowledgements

This work was supported by the Stavros Niarchos Complex Joint Reconstruction Center at Hospital for Special Surgery. The content is solely the responsibility of the authors and does not necessarily represent the official views of the center.

Disclosure of Interests

J. Alex Gibbons: None declared, Orett Burke Jr: None declared, Huong Do: None declared, Emily Ying Lai: None declared, Bella Mehta Paid instructor for: Novartis, Letitia Bradford: None declared, Michael Parks Consultant of: ZimmerBiomet, Linda Russell: None declared, Anne Bass: None declared, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis

POS0285 ARE RACIAL DISPARITIES IN REVISION TKA OUTCOMES ASSOCIATED WITH HOSPITAL OR SURGEON VOLUME?

Background:

Total knee arthroplasty (TKA) outcomes are linked to surgical volume,1 despite the increase in TKA utilization, racial disparities in TKA outcomes persist. Blacks in the US are at a higher risk of aseptic revision of TKA (R-TKA) when compared to Whites, yet the reasons for this are not understood.

Objectives:

The objective of this study is to examine the relationship between hospital and surgeon annual TKA volume and R-TKA outcomes by race.

Methods:

This is an observational cohort study. New York Statewide Planning and Research Cooperative System data for 2004 – 2013 was used to identify patients who underwent primary TKA. Data through 2015 was used to identify R-TKA within 2 years of the index TKA. Hospital characteristics were obtained from the AHA Annual Survey. Surgeon data was collected from New York State Education Department and New York State Physician Profile. Surgeon annual TKA volume was categorized based on cutoffs established by Wilson et al1 as </=12, 13-59, 60-145 or >/= 146, and hospital TKA volume as </=89, 90-235, 236-644 and >/=645. We calculated the odds of R-TKA in Whites and Blacks separately and generated crude odds ratios (OR) comparing Blacks to Whites to examine trends across volume categories. A multivariable logistic regression model adjusted for known R-TKA risk factors was also performed.

Results:

A total of 163,576 patients were included. Mean (SD) age was 66.4 (10.4) years, 107,233 (65.6%) were female, 124,277 (76.6%) were White and 15,990 (9.8%) were Black. 2925 patients underwent aseptic R-TKA. In logistic regression analysis, Blacks had a higher risk of R-TKA (OR 1.42, 95%CI 1.26-1.6) (Table 1). Risk of R-TKA was also higher when surgeon annual volume was </=12 (OR 1.5, 95%CI 1.25-1.8) or 13-59 (OR 1.16, 95%CI 1.04-1.29) TKA compared to the highest volume surgeons (>/=146). Patients who had surgery at a hospital with annual volume of 236-634 TKA were less likely to undergo R-TKA compared to the highest volume hospitals (>/=645) (OR 0.88, 95%CI 0.79-0.98). Other risk factors for R-TKA were younger age and worker’s compensation, while patients with inflammatory arthritis had a lower risk. Figures 1A and 1B show the odds of R-TKA in Whites and Blacks, respectively, by hospital and surgeon volume. Figure 1C shows the crude OR for Blacks to Whites for each category pair. The OR ranged from 0.9 to 2.5, with the largest disparity found in patients who have TKA performed by surgeons with 60-145 annual TKA volume at the highest volume hospitals (>/=645).

Conclusion:

Patients having TKA by a surgeon performing <60 TKA per year have higher risk of R-TKA. Racial disparities in R-TKA risk are highest for TKA by surgeons performing 60-145 TKA per year at hospitals performing >/=645 TKA per year. Future studies should examine factors, such as whether trainees are involved the surgery, that may vary based on social determines of health, such as patient race and payor.

References:

[1]Wilson S. et al Meaningful thresholds for the volume-outcome relationship in total knee arthroplasty. Journal of bone and joint surgery. 2016;98:1683

Table 1.

Logistic regression of risk for R-TKA

Variable (reference)LevelOdds ratio95% CIp-valueAge--0.950.94-0.95<.001Sex (female)Male1.070.99-1.150.108Race (whiteAsian0.650.42-0.960.031Black1.421.26-1.6<.001Unknown0.810.64-1.020.07Other1.050.92-1.210.446Insurance (Medicare)Medicaid0.890.75-1.060.193Other0.890.7-1.130.331Private0.820.74-0.91<.001Work compensation1.561.35-1.8<.001Surgeon volume (>/=146)</=121.51.25-1.8<.00113-591.161.04-1.290.00660-1451.00.91-1.110.957Hospital volume (>/=645)</= 890.980.84-1.150.84890-2350.990.88-1.120.869236-6440.880.79-0.980.018Hospital bed size (>400 beds)6-1991.131.02-1.250.024200-3991.060.96-1.170.262

Other variables in model: diabetes, obesity, renal disease, COPD, osteoarthritis, osteonecrosis, dislocation, inflammatory arthritis, surgical complication, infection, no college, poverty >20%, years since residency, US/Canada medical school, orthopedic board certified, AHA control, teaching, rural hospital

Disclosure of Interests:

Serene Mirza: None declared, Susan Goodman: None declared, Yi Zhang: None declared, Huong Do: None declared, Bella Mehta: None declared, Stephen Lyman: None declared, Lisa A. Mandl: None declared, Mark Figgie: None declared, Michael Parks Consultant of: Zimmer biomet, Grant/research support from: Zimmer biomet, Linda Russell: None declared, Anne Bass: None declared

Associations between the IASLC/ATS/ERS lung adenocarcinoma classification and EGFR and KRAS mutations

We sought to investigate the frequency of mutations in epidermal growth factor receptor (EGFR) and Kirsten-RAS (KRAS) by each pathological subtype for patients with resected pulmonary adenocarcinoma as defined by the IASLC/ATS/ERS classification. Histological examination determined the predominant subtype according to the IASLC/ATS/ERS classification. EGFR and KRAS mutations were determined by high-resolution melting and Sanger sequencing. Clinical data were collected from medical records and clinicians. The 178 consecutive patients consisted of 48% males, median age 68 years (range 20-87) and smoking history 78%. The tumour stage was I in 62%, II in 18% and III in 20%. The mutation rates were: EGFR 30%; KRAS 28%. The rate of EGFR mutations in the acinar predominant reference group (n=76), was 37%. The solid predominant subtype showed significantly fewer EGFR mutations [3/33 (9%), odds ratio 0.17 (0.05-0.61), p=0.007]. No differences in mutation rate were observed in other subtypes. No association was found between KRAS mutations and predominant histological subtype. Advanced stage and solid predominant subtype were negative prognostic factors. EGFR mutations can be present in adenocarcinoma of any predominant subtype, however rarely in solid predominant tumours. No association was found between KRAS mutation and the predominant histological subtype.

Evaluation of the foot and ankle outcome score in patients with osteoarthritis of the ankle

The foot and ankle outcome score (FAOS) has been evaluated for many conditions of the foot and ankle. We evaluated its construct validity in 136 patients with osteoarthritis of the ankle, its content validity in 37 patients and its responsiveness in 39. Data were collected prospectively from the registry of patients at our institution.

All FAOS subscales were rated relevant by patients. The Pain, Activities of Daily Living, and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2. All subscales except Symptoms were responsive to change after surgery.

We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle. However, some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments.

Cite this article: Bone Joint J 2015; 97-B:662–7.

Targeting IL-6 by both passive or active immunization strategies prevents bleomycin-induced skin fibrosis

Introduction

Interleukin-6 (IL-6) is a pleiotropic cytokine for which preliminary data have suggested that it might contribute to systemic sclerosis (SSc). Our aims were to investigate, firstly, IL-6 expression in patients with SSc and, secondly, the efficacy of both passive and active immunization against IL-6 to reduce skin fibrosis in complementary mouse models of SSc.

Methods

Human serum levels and skin expression of IL-6 were determined by enzyme-linked immunosorbent assay and immunohistochemistry, respectively. We first evaluated the antifibrotic properties of the monoclonal anti-IL-6R antibody, MR16-1, in the bleomycin-induced dermal fibrosis mouse model, reflecting early and inflammatory stages of SSc. Then, we assessed the efficacy of MR16-1 in tight skin-1 (Tsk-1) mice, an inflammation-independent model of skin fibrosis. Additionally, we have developed an innovative strategy using an anti-IL-6 peptide-based active immunization. Infiltrating leukocytes, T cells, and B cells were quantified, and IL-6 levels were measured in the serum and lesional skin of mice after passive or active immunization.

Results

Serum and skin levels of IL-6 were significantly increased in patients with early SSc. Treatment with MR16-1 led in the bleomycin mouse model to a 25% (P = 0.02) and 30% (P = 0.007) reduction of dermal thickness and hydroxyproline content, respectively. MR16-1 demonstrated no efficacy in Tsk-1 mice. Thereafter, mice were immunized against a small peptide derived from murine IL-6 and this strategy led in the bleomycin model to a 20% (P = 0.02) and 25% (P = 0.005) decrease of dermal thickness and hydroxyproline content, respectively. Passive and active immunization led to decreased T-cell infiltration in the lesional skin of mice challenged with bleomycin. Upon bleomycin injections, serum and skin IL-6 levels were increased after treatment with MR16-1 and were significantly reduced after anti-IL-6 active immunization.

Conclusions

Our results support the relevance of targeting IL-6 in patients with early SSc since IL-6 is overexpressed in early stages of the disease. Targeting IL-6 by both passive and active immunization strategies prevented the development of bleomycin-induced dermal fibrosis in mice. Our results highlight the therapeutic potential of active immunization against IL-6, which is a seductive alternative to passive immunization.

Symptomatic pulmonary embolism after outpatient arthroscopic procedures of the knee: the incidence and risk factors in 418,323 arthroscopies

Pulmonary embolism is a serious complication after arthroscopy of the knee, about which there is limited information. We have identified the incidence and risk factors for symptomatic pulmonary embolism after arthroscopic procedures on outpatients. The New York State Department of Health Statewide Planning and Research Cooperative System database was used to review arthroscopic procedures of the knee performed on outpatients between 1997 and 2006, and identify those admitted within 90 days of surgery with an associated diagnosis of pulmonary embolism. Potential risk factors included age, gender, complexity of surgery, operating time defined as the total time that the patient was actually in the operating room, history of cancer, comorbidities, and the type of anaesthesia. We identified 374,033 patients who underwent 418,323 outpatient arthroscopies of the knee. There were 117 events of pulmonary embolism (2.8 cases for every 10 000 arthroscopies). Logistic regression analysis showed that age and operating time had significant dose-response increases in risk (p < 0.001) for a subsequent admission with a pulmonary embolism. Female gender was associated with a 1.5-fold increase in risk (p = 0.03), and a history of cancer with a threefold increase (p = 0.05). These risk factors can be used when obtaining informed consent before surgery, to elevate the level of clinical suspicion of pulmonary embolism in patients at risk, and to establish a rationale for prospective studies to test the clinical benefit of thromboprophylaxis in high-risk patients.

Biochemical and pharmacological characterization of different recombinant acid alpha-glucosidase preparations evaluated for the treatment of Pompe disease

Pompe disease results in the accumulation of lysosomal glycogen in multiple tissues due to a deficiency of acid alpha-glucosidase (GAA). Enzyme replacement therapy for Pompe disease was recently approved in Europe, the U.S., Canada, and Japan using a recombinant human GAA (Myozyme, alglucosidase alfa) produced in CHO cells (CHO-GAA). During the development of alglucosidase alfa, we examined the in vitro and in vivo properties of CHO cell-derived rhGAA, an rhGAA purified from the milk of transgenic rabbits, as well as an experimental version of rhGAA containing additional mannose-6-phosphate intended to facilitate muscle targeting. Biochemical analyses identified differences in rhGAA N-termini, glycosylation types and binding properties to several carbohydrate receptors. In a mouse model of Pompe disease, glycogen was more efficiently removed from the heart than from skeletal muscle for all enzymes, and overall, the CHO cell-derived rhGAA reduced glycogen to a greater extent than that observed with the other enzymes. The results of these preclinical studies, combined with biochemical characterization data for the three molecules described within, led to the selection of the CHO-GAA for clinical development and registration as the first approved therapy for Pompe disease.