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INTRODUCTION: In response to the opioid epidemic, a multitude of policy and clinical-guideline based interventions were launched to combat physician overprescribing. However, the sudden rise of the Covid-19 pandemic disrupted all aspects of healthcare delivery. The purpose of this study was to evaluate how opioid prescribing patterns changed during the Covid-19 pandemic within a large multispecialty orthopedic practice. MATERIALS AND METHODS: A retrospective review of 1,048,559 patient encounters from January 1, 2015 to December 31, 2022 at a single orthopedic practice was performed. Primary outcomes were the percent of encounters with opioids prescribed and total morphine milligram equivalents (MMEs) per opioid prescription. Differences in outcomes were assessed by calendar year. Encounters were then divided into two groups: pre-Covid (1/1/2019-2/29/2020) and Covid (3/1/2020-12/31/2022). Univariate analyses were used to evaluate differences in diagnoses and outcomes between periods. Multivariate analysis was performed to assess changes in outcomes during Covid after controlling for differences in diagnoses. Statistical significance was assessed at p < 0.05. RESULTS: The percentage of encounters with opioids prescribed decreased from a high of 4.0% in 2015 to a low of 1.6% in 2021 and 2022 (p < 0.001). MMEs per prescription decreased from 283.6 ± 213.2 in 2015 to a low of 138.6 ± 100.4 in 2019 (p < 0.001). After adjusting for diagnoses, no significant differences in either opioid prescribing rates (post-COVID OR = 0.997, p = 0.893) or MMEs (post-COVID ß = 2.726, p = 0.206) were observed between the pre- and post-COVID periods. CONCLUSION: During the Covid-19 pandemic opioid prescribing levels remained below historical averages. While continued efforts are needed to minimize opioid overprescribing, it appears that the significant progress made toward this goal was not lost during the pandemic era.
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Analgésicos Opioides , COVID-19 , Pautas de la Práctica en Medicina , Humanos , COVID-19/epidemiología , Analgésicos Opioides/uso terapéutico , Estudios Retrospectivos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/tendencias , Masculino , Femenino , Pandemias , SARS-CoV-2 , Persona de Mediana Edad , Prescripciones de Medicamentos/estadística & datos numéricos , Ortopedia , AdultoRESUMEN
Background: As life expectancy improves for patients with dementia, the demand for mobility-improving surgeries such as total joint arthroplasty (TJA) will increase. There is little research on patients with dementia undergoing TJA, although dementia has been shown to be a risk factor for complications. The purpose of this study is to compare postoperative outcomes of patients with dementia undergoing TJA at 90 days, 2 years, and 5 years. Methods: The TriNetX database was retrospectively queried for all patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were divided into cohorts by preoperative diagnosis of dementia and propensity score matched. The following outcomes were evaluated between groups at 90 days, 2 years, and 5 years postoperatively: revision, resection arthroplasty, closed reduction (THA only), femur fracture plating, and prosthetic joint infection. Readmission and manipulation under anesthesia (TKA only) were evaluated at 90 days postoperatively. Univariate and multivariate analyses were performed. Results: After matching, there were no differences in demographics or comorbidities between groups. TKA (odds ratio [OR] = 1.75, 95% confidence interval [CI] 1.42-2.15, P < .001) and THA (OR = 2.17, 95% CI 1.92-2.45, P < .001) patients with dementia were more likely to be readmitted than patients without dementia. At 2 years (OR = 2.07, 95% CI 1.14-3.77, P = .015) and 5 years (OR = 2.14, 95% CI 1.32-3.48, P = .002) postoperatively, THA patients with dementia were more likely to have proximal femur fracture plating than patients without dementia. Conclusions: Patients undergoing THA with dementia had worse outcomes than patients undergoing THA without dementia and TKA with dementia. The overall rate of complications was low, and a diagnosis of dementia should not be an absolute contraindication to proceeding with TJA.
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BACKGROUND: Total knee arthroplasty (TKA) is a common surgical procedure performed to alleviate pain and improve functional outcomes in patients with knee osteoarthritis and rheumatoid arthritis who have failed conservative treatments. Arthrofibrosis has been extensively studied due to its negative impact on TKA outcomes. Losartan, an angiotensin receptor blocker (ARB), has the potential to improve TKA outcomes by inhibiting TGF-ß and decreasing fibrosis. This study aims to analyze a large-scale, real-world healthcare database to investigate the association between losartan potassium prescription and postoperative outcomes such as readmissions, ED visits, and the need for MUA or revision TKA. HYPOTHESIS: Based on previous literature and the nature of ARBs, it is expected that the addition of losartan will aid in better outcomes for patients following a primary TKA. PATIENTS AND METHODS: In this retrospective observational study, the TriNetX Research Network (TriNetX) database was queried as of June 21, 2023. All patients who underwent a primary total knee arthroplasty (TKA) prior to June 21, 2022 were included. Patients were then divided into two cohorts by whether they had an active losartan potassium prescription within the year prior to their surgery to within 90days postoperatively. Patients were then propensity-matched to eliminate differences in demographics and comorbidities. RESULTS: Losartan TKA patients were 1.18 [OR: 0.85 (95% CI: 0.79-0.90), p<0.001] times less likely to be readmitted within 90days and were 1.15 (OR: 0.87 (95% CI: 0.79-0.96); p=0.009) times less likely to undergo a manipulation under anesthesia (MUA) within the 1-year postoperative period. There were no statistically significant differences in rates of emergency department (ED) visits at 90days postoperatively or revision TKAs at 1year postoperatively. DISCUSSION: In conclusion, patients with an active losartan prescription prior to TKA had a significantly lower likelihood of readmission within 90days and a lower likelihood of undergoing MUA within the 1-year postoperative period compared to patients not taking losartan. This presents an opportunity for further clinical investigation to explore the value of losartan in TKA. LEVEL OF EVIDENCE: III; an observational cohort study.
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Mercury (Hg) is a toxic metal that is easily released into the atmosphere as a gas or a particulate. Since Hg has serious health impacts based on human exposure, it is a major concern where it accumulates. Southern Florida is a region of high Hg deposition in the United States. It has entered the southern Florida environment for over 56 MY. For the past 3000 to 8000 years, Hg has accumulated in the Everglades peatlands, where approximately 42.3 metric tons of Hg was deposited. The pre-industrial source of mercury that was deposited into the Everglades was from the atmosphere, consisting of combined Saharan dust and marine evasion. Drainage and the development of the Everglades for agriculture, and other mixed land uses have caused a 65.7% reduction in the quantity of peat, therefore releasing approximately 28 metric tons of Hg into the southern Florida environment over a period of approximately 133 years. Both natural and man-made fires have facilitated the Hg release. The current range in mercury release into the southern Florida environment lies between 994.9 and 1249 kg/yr. The largest source of Hg currently entering the Florida environment is from combined atmospheric sources, including Saharan dust, aerosols, sea spray, and ocean flux/evasion at 257.1-514.2 kg/yr. The remobilization of Hg from the Everglades peatlands and fires is approximately 215 kg/yr. Other large contributors include waste to energy incinerators (204.1 kg/yr), medical waste and crematory incinerators (159.7+ kg/yr), and cement plant stack discharge (150.6 kg/yr). Minor emissions include fuel emissions from motorized vehicles, gas emissions from landfills, asphalt plants, and possible others. No data are available on controlled fires in the Everglades in sugar farming, which is lumped with the overall peatland loss of Hg to the environment. Hg has impacted wildlife in southern Florida with recorded excess concentrations in fish, birds, and apex predators. This bioaccumulation of Hg in animals led to the adoption of regulations (total maximum loads) to reduce the impacts on wildlife and warnings were given to consumers to avoid the consumption of fish that are considered to be contaminated. The deposition of atmospheric Hg in southern Florida has not been studied sufficiently to ascertain where it has had the greatest impacts. Hg has been found to accumulate on willow tree leaves in a natural environment in one recent study. No significant studies of the potential impacts on human health have been conducted in southern Florida, which should be started based on the high rates of Hg fallout in rainfall and known recycling for organic sediments containing high concentrations of Hg.
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Mercurio , Animales , Humanos , Mercurio/análisis , Salud Pública , Florida , Monitoreo del Ambiente , Peces , PolvoRESUMEN
INTRODUCTION: Multiple studies demonstrate social deprivation is associated with inferior outcomes after total hip (THA) and total knee (TKA) arthroplasty; its effect on patient-reported outcomes is debated. The primary objective of this study evaluated the relationship between social vulnerability and the PROMIS-PF measure in patients undergoing THA and TKA. A secondary aim compared social vulnerability between patients who required increased resource utilization or experienced complications and those who didn't. MATERIALS AND METHODS: A retrospective review of 537 patients from March 2020 to February 2022 was performed. The Centers for Disease Control Social Vulnerability Index (SVI) were used to quantify socioeconomic disadvantage. The cohort was split into THA and TKA populations; univariate and multivariate analyses were performed to evaluate primary and secondary outcomes. Statistical significance was assessed at p < 0.05. RESULTS: 48.6% of patients achieved PROMIS-PF MCID at 1-year postoperatively. Higher levels of overall social vulnerability (0.40 vs. 0.28, p = 0.03) were observed in TKA patients returning to the ED within 90-days of discharge. Increased overall SVI (OR = 9.18, p = 0.027) and household characteristics SVI (OR = 9.57, p = 0.015) were independent risk factors for 90-day ED returns after TKA. In THA patients, increased vulnerability in the household type and transportation dimension was observed in patients requiring 90-day ED returns (0.51 vs. 0.37, p = 0.04). CONCLUSION: Despite an increased risk for 90-day ED returns, patients with increased social vulnerability still obtain good 1-year functional outcomes. Initiatives seeking to mitigate the effect of social deprivation on TJA outcomes should aim to provide safe alternatives to ED care during early recovery.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Vulnerabilidad Social , Artroplastia de Reemplazo de Cadera/métodos , Articulación de la Rodilla , Alta del Paciente , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Various episode-of-care bundled payment models for patients undergoing total joint arthroplasty have been implemented. However, participation in bundled payment programs has dropped given the challenges of meeting continually lower target prices. The purpose of our study is to investigate the cost of outpatient physical therapy (PT) and the potential for stand-alone outpatient PT bundled payments for patients undergoing total hip arthroplasty (THA). METHODS: A retrospective review of 501 patients who underwent primary unilateral THA from November 2017 to February 2020 was performed. All patients included in this study received postoperative PT care at a single hospital-affiliated PT practice. Patients above the 75th percentile of therapy visits were then classified as high-PT utilizers and compared with the rest of the population using univariate statistics. Stepwise multivariate logistic regression was used to assess the predictors of high therapy utilization. RESULTS: Patients averaged 65 ± 10 years of age and a BMI of 29 ± 5 kg/m2. Overall, 80% of patients were white and 53% were female. The average patient had 11 ± 8 total therapy sessions in 42 days: one initial evaluation, one re-evaluation and 9 standard sessions. High-PT utilizers incurred estimated average costs of $1934 ± 431 per patient, compared to $783 ± 432 (P < 0.001) in the rest of the population. Further, no significant differences in 90-day outcomes including lower extremity functional scale scores, emergency department returns, readmissions, or returns to the operating room were observed between high utilizers and the rest of the population (all P > 0.08). In the multivariate analysis, women (OR = 1.68, P = 0.017) and those with sleep apnea (OR = 2.02, P = 0.012) were nearly twice as likely to be high utilizers, while white patients were 42% less likely to be high utilizers than patients of other races (OR = 0.58, P = 0.028). CONCLUSIONS: Outpatient PT utilization is highly variable in patients undergoing THA. However, despite using more services and incurring increased cost, patients in the top quartile of utilization experienced similar outcomes to the rest of the population. If outpatient therapy bundles are to be developed, 16 visits appear to be a reasonable target for pricing, given this provides adequate coverage for 75% of THA patients.
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Background: As length of stay after total knee arthroplasty (TKA) continues to shorten, interventions that may reduce early postoperative pain and complications must be studied. Peripheral nerve block is being explored as a potential means of improving pain management. The purpose of this study was to evaluate the impact of adductor canal block (ACB) on postoperative outcomes for patients undergoing TKA. Methods: We conducted a retrospective review of 565 patients who received unilateral TKA under spinal anesthesia with a periarticular anesthetic injection. Patients were divided by ACB status. Univariate comparisons and multivariate regression were used to compare outcomes for patients receiving ACBs vs those who did not. Results: Of the 565 patients, 167 received an ACB, and 398 did not. Patients who received an ACB were less likely to require nausea medication during the immediate postoperative period. Length of stay, narcotic consumption, rate of discharge to home, postanesthesia care unit recovery time, urinary retention, ability to complete physical therapy, and 30-day readmission rate did not differ significantly between groups. After risk adjustment, the only significant finding was decreased likelihood of nausea in patients receiving an ACB. Conclusion: ACBs appear to have little to no significant impact on early clinical outcomes in patients having TKA under spinal anesthesia with a periarticular anesthetic injection. Further study of larger patient cohorts is required to validate these findings.
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INTRODUCTION: Total joint arthroplasty (TJA) is a highly effective surgery. However, poor nutritional status has been associated with worse outcomes. In orthopedics, nutrition status is commonly evaluated using serum albumin. When albumin levels fall below 3.0 g/dL, wound healing ability becomes impaired. Typically, malnutrition is associated with low BMI, but malnourished patients can also be obese. The goals of this study were to investigate the relationship between malnourishment represented through albumin levels of obese patients and likelihood of postoperative complications. METHODS: A retrospective review of patients undergoing primary TJA from 2016 to 2020 in the American College of Surgeons National Surgical Quality Improvement Program national database was performed. Patients with an albumin of < 3.5 g/dL were considered to have hypoalbuminemia and those with ≥ 3.5 g/dL were considered normal albumin. Univariate analysis was used to determine demographic and comorbidity differences between those with and without hypoalbuminemia. Outcomes of interest included length of stay, resource utilization, discharge disposition, and unplanned readmissions. Multivariate logistic regression examined albumin as a predictor of increased resource utilization and complications after controlling for possible confounding variables. RESULTS: Of the 79,784 patients, 4.96% of patients had low albumin. Those with hypoalbuminemia were nearly 1.5 years older than those with normal albumin, were more likely to be black, female, and had an overall increased comorbidity burden as shown by percent of patients with ASA > 3 (all p < 0.001). After risk adjustment, those with hypoalbuminemia and a BMI of 35 + had greater risk of complications and increased resource utilization. CONCLUSION: Our results demonstrated the prevalence of malnutrition increases as a patient's BMI increases. Further, hypoalbuminemia was associated with increased resource utilization and increased complication rates in all obese patients. We suggest screening albumin levels in obese patients preoperatively to give surgeons the best opportunity to optimize patient nutrition before undergoing surgery.
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Hipoalbuminemia , Desnutrición , Humanos , Femenino , Hipoalbuminemia/complicaciones , Hipoalbuminemia/epidemiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico , Obesidad/complicaciones , Albúmina Sérica/análisis , Artroplastia/efectos adversos , Estudios Retrospectivos , Desnutrición/complicaciones , Factores de RiesgoRESUMEN
Background: Health disparities disproportionately affect minority groups across the United States with respect to care access, quality, and outcomes. The aim of this study is to examine existing disparities between white and African American (AA) patients regarding postoperative outcomes following total joint arthroplasty and provide insight into disparity trends over a 9-year period. Methods: A retrospective review of 16,779 total joint arthroplasty patients at a single institution between January 2013 and December 2021 was performed. Patients were grouped by race as AA or white. Outcomes of interest included length of stay (LOS), home discharge, 30-day emergency department return, and 30-day readmission. Univariate statistics and multivariate regressions were utilized to analyze results. Results: Significant improvements in LOS and rates of home discharge occurred for both white and AA patients at our institution over a 9-year period, while rates of 30-day emergency department returns and readmissions demonstrated a downward but non-statistically significant trend. Despite these trends, AA patients continued to experience longer lengths of stay, less likelihood of 0- or 1-day LOS, and higher risk of nonhome discharge for most years examined. However, after controlling for demographic and comorbidity differences, the differences between groups narrowed over time resulting in no significant differences in the aforementioned 3 measures by 2021. Conclusions: Although racial disparities in outcomes are still apparent, over time, the differences in resource utilization between AA and white patients have narrowed. Initiatives aimed at creating healthier communities with increased access to care and the ultimate goal of equitable care must continue to be pursued.
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BACKGROUND: Spinal anesthesia (SA) has been previously associated with improved outcomes after total joint arthroplasty (TJA). The purpose of this study was to compare outcomes between various local anesthetics. METHODS: This was a retrospective study of 1,328 patients undergoing primary TJA with SA from September 2020-2021 at a single institution. Patients were grouped based on TKA or THA and further separated and analyzed in terms of anesthetic agents-mepivacaine (M), hyperbaric bupivacaine (HB), or isobaric bupivacaine (IB). Subgroup analysis of same-day-discharge (SDD) patients and low- (<11 mg) and high-dose bupivacaine was performed. Statistical significance was assessed at P<0.05. RESULTS: Mepivacaine use was associated with younger age, lower ASAs, and lower Charlson Comorbidity Index (CCI) scores in both THAs and TKAs. Postoperatively, significant differences were found between HB, IB, and M in LOS, the first PT ambulation distance and rates of SDD, and home discharge in both THAs and TKAs. No significant differences in outcomes were observed between high- and low-dose bupivacaine in THAs or TKAs. In SDD patients, a significant difference was found only in the first 6-clicks mobility scores. After controlling for age, BMI, sex, ASA, and procedure type, mepivacaine was found to be associated with shorter LOS, increased likelihood of SDD, home discharge, POD-0 ambulation, and, further, the first ambulation distance. No significant differences were observed in 6-clicks mobility scores, urinary retention, 30-day ED returns or 30-day readmissions. CONCLUSIONS: Both bupivacaine and mepivacaine are safe and effective local anesthetics for patients undergoing TJA as evidenced by low, similar rates of urinary retention and 30-day ED returns and readmissions. Mepivacaine does appeared to facilitate early ambulation, shorter LOS and home discharge and should be considered as the local anesthetic of choice for patients undergoing rapid recovery TJA.
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BACKGROUND: The purpose of this study was to evaluate the relationship between lower extremity functional scale (LEFS) scores with postoperative functional outcomes for total joint arthroplasty (TJA) patients and to investigate the utility of this tool to create an individualized plan of care perioperatively. METHODS: Patients undergoing primary TJA at a single institution from 2016 to 2019 was retrospectively reviewed by a univariate analysis in terms of patient characteristics and outcomes across LEFS quartiles. Multivariate regression models were constructed to evaluate the association between the LEFS quartile and outcomes after controlling for confounding factors. RESULTS: A total of 1389 patients were included. All patients had a documented LEFS pre- and postoperatively with the last value documented at least 60 days to a maximum of 1 year after surgery. The following cutoffs for LEFS quartiles were observed: quartile 1 preoperative LEFS ≤27, quartile 2 ranges from 28 to 35, quartile 3 ranges from 36 to 43, and quartile 4 ≥ 44. Patients with a higher comorbidity burden and ASA score were more likely to have a lower LEFS. Higher levels of preoperative function were significantly associated with shorter LOS and higher rates of same day discharge, independent ambulation, mobility and activity scores, and rates of discharge home. CONCLUSION: These findings suggest that LEFS is a useful tool for aiding clinical resource allocation decisions, and incorporation of the measure into existing predictive models may improve their accuracy.
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BACKGROUND: Maryland Health Enterprise Zones (MHEZs) were introduced in 2012 and encompass underserved areas and those with reduced access to healthcare providers. Across the United States many underserved and minority populations experience poorer total joint arthroplasty (TJA) outcomes seemingly because they reside in underserved areas. The purpose of this study is to identify and quantify the relationship between living in an MHEZ and TJA outcomes. METHODS: Retrospective review of 11,451 patients undergoing primary TJA at a single institution from July 1, 2014 to June 30, 2020 was conducted. Patients were classified based on whether they resided in an MHEZ. Statistical analyses were used to compare outcomes for TJA patients who live in MHEZ and those who do not. RESULTS: Of the 11,451 patients, 1057 patients lived in MHEZ and 10,394 patients did not. After risk adjustment, patients who live in an MHEZ were more likely to return to the emergency department within 90 days postoperatively and were less likely to be discharged home than those patients who do not live in an MHEZ. CONCLUSION: Total joint arthroplasty patients residing in MHEZ appear to present with poorer overall health as measured by increased American Society of Anesthesiologists and Hierarchical Condition Categories scores, and they are less likely to be discharged home and more likely to return to the emergency department within 90 days. Several factors associated with these findings such as socioeconomic factors, household composition, housing type, disability, and transportation may be modifiable and should be targets of future population health initiatives.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Servicio de Urgencia en Hospital , Humanos , Área sin Atención Médica , Alta del Paciente , Estudios Retrospectivos , Factores de Riesgo , Estados UnidosRESUMEN
We examined the effect of varying multimodal pain management (MMPM) combinations on oral morphine milligram equivalents (OMME) and length of stay (LOS) after total knee arthroplasty (TKA). Five groups were compared based on the combination of multimodal analgesics ranging from no MMPM to full MMPM with acetaminophen, gabapentinoids, and celecoxib. After risk adjustment, MMPM was associated with decreased odds of LOS ≥2 days and OMME ≥75th percentile. MMPM protocols are effective at reducing LOS and postoperative narcotic requirements post-TKA. Patients appear to derive similar benefit from receiving all three medications, as well as various combinations of these drugs.
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BACKGROUND: Nurse navigation programs have been previously shown to reduce cost and improve outcomes after total joint arthroplasty (TJA). Medicare has proposed a 13.7% reduction in professional fee reimbursement for TJA procedures that may adversely impact providers' and health systems' ability to fund ancillary support resources such as nurse navigators. METHODS: A consecutive series of primary TJAs performed between April 2019 and February 2020 was retrospectively reviewed. Clinical and financial outcomes of patients attending a nurse navigator-led preoperative education class were compared with those who did not attend. RESULTS: There were 2057 TJAs identified during the study period. Most patients attended the preoperative education class (82.7%) and were discharged home (92.8%). Controlling for significant differences between groups, class attendance was associated with reduced length of stay (LOS), increased chance of 0- or 1-day LOS, reduced chance of discharge to a skilled nursing facility, and reduced hospital charges. For this patient sample, a proposed 13.7% reduction in nurse navigator-led classes was modeled to increase overall cost to payers by >$400,000 annually. Complete elimination of this class was estimated to increase the total annual cost by >$5,700,000 and cost per TJA by >$2700. CONCLUSION: The use of a nurse navigator-led preoperative education class was associated with shorter LOS, more frequent 0- and 1-day LOS, reduced discharge to skilled nursing facilities, and lower total hospital charges for those patients who attended. Potential reductions proposed by Medicare may interfere with the ability to support such services and negatively impact both clinical and financial outcomes.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Anciano , Humanos , Tiempo de Internación , Medicare , Alta del Paciente , Estudios Retrospectivos , Instituciones de Cuidados Especializados de Enfermería , Estados UnidosRESUMEN
INTRODUCTION: Knee osteoarthritis (OA) is a leading cause of disability and functional limitations in aging adults. Total knee arthroplasty (TKA) is the gold standard treatment of this condition. The purpose of this study is to evaluate which patient characteristics are associated with proceeding to TKA. METHODS: Retrospective review of patients with knee osteoarthritis at a single institution was conducted. Demographic, radiographic and clinical patient characteristics were analyzed. The primary outcome measure was whether patients underwent TKA over the study time-period. Univariate comparisons between patients not undergoing surgery and those undergoing TKA were performed. Multivariate logistic regression was performed to evaluate risk factors for undergoing TKA. RESULTS: Two hundred seven patients were included in the study. One hundred eighty seven patients (90.3%) did not undergo surgery, while 20 (9.7%) underwent TKA. No statistically significant differences in demographics were observed between patients who underwent TKA and those who did not. On multivariate analysis, patients with Kellgren Lawrence grade 4 OA (OR: 20.793, p = 0.009) and varus alignment (OR: 13.044, p = 0.040) were at significantly increased risk of undergoing TKA. Using only these two variables, the area under the curve for predicting which patients would undergo TKA was 0.846, indicating excellent discrimination. CONCLUSION: In patients diagnosed with knee OA, Kellgren Lawrence grade 4 classification and varus knee alignment are significant risk factors for undergoing TKA, and are associated with a decreased time from initial presentation to surgery. These findings may be used to counsel patients, aid triage decisions, and inform the development of future predictive models.
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BACKGROUND: In January 2020, The Centers for Medicare and Medicaid Services approved total knee arthroplasty (TKA) to be performed in ambulatory surgery centers (ASCs). This study aims to develop a predictive model for targeting appropriate patients for ASC-based TKA. METHODS: A retrospective review of 2266 patients (205 same-day discharge [SDD; 9.0%] and 2061 one-day length of stay [91.0%]) undergoing TKA at a regional medical center between July 2016 and September 2020 was conducted. Multiple logistic regression was used to evaluate predictors of SDD, as these patients represent those most likely to safely undergo TKA in an ASC. RESULTS: Controlling for other demographics and comorbidities, patients with the following characteristics were at reduced odds of SDD: increased age (odds ratio [OR] = 0.935, P < .001), body mass index ≥35 (OR = 0.491, P = .002), female (OR = 0.535, P < .001), nonwhite race (OR = 0.456, P = .003), primary hypertension (OR = 0.710, P = .032), ≥3 comorbidities (OR = 0.507, P = .002), American Society of Anesthesiologists score ≥3 (OR = 0.378, P < .001). The model was deemed to be of adequate fit using the Hosmer and Lemeshow test (χ2 = 12.437, P = .112), and the area under the curve was found to be 0.773 indicating acceptable discrimination. CONCLUSION: For patients undergoing primary TKA, increased age, body mass index ≥35, female gender, nonwhite race, primary hypertension, ≥3 comorbidities, and American Society of Anesthesiologists score ≥3 decrease the likelihood of SDD. A predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in identifying patients that are candidates for SDD or ASC-based TKA.
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BACKGROUND: Dexamethasone has been shown to reduce postoperative pain and opioid consumption for total joint arthroplasty patients; however, its impact on patients who received neuraxial anesthesia (NA) is not well described. We examined the impact of perioperative dexamethasone on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA) under NA. METHODS: A retrospective review was conducted for 376 THA patients from a single institution. Univariate analysis was used to compare postoperative outcomes for 164 THA patients receiving dexamethasone compared to 212 who did not receive dexamethasone. RESULTS: No differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) Score were observed between the groups. Patients receiving perioperative dexamethasone reported statistically significantly lower postanesthesia care unit (PACU) pain numeric rating scale (Dexamethasone 1.6 vs No dexamethasone 2.3, P = .014) and received lower PACU morphine milligram equivalents (MME) (Dexamethasone 8.57 vs No dexamethasone 11.44, P < .001). Patients receiving dexamethasone had significantly shorter LOS (Dexamethasone 29.40 vs No dexamethasone 35.26 hrs., P < .001). CONCLUSION: Perioperative dexamethasone is associated with decreased postoperative pain and narcotic consumption, and shorter length of stay for patients undergoing primary direct anterior approach THA with NA.
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Anestesia , Artroplastia de Reemplazo de Cadera , Analgésicos Opioides , Artroplastia de Reemplazo de Cadera/efectos adversos , Dexametasona , Humanos , Tiempo de Internación , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/epidemiología , Dolor Postoperatorio/etiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Recent literature has suggested some benefits for neuraxial anesthesia (NA) as an alternative for general anesthesia (GA) for primary total hip arthroplasty patients. We examined the impact of NA vs GA on outcomes for patients undergoing direct anterior (DA) approach total hip arthroplasty (THA) in an institution with established rapid recovery protocols. METHODS: A retrospective review was conducted for 500 consecutive THA patients from a single institution. Univariate analysis and multivariate linear regression were used to compare outcomes for THA patients receiving NA and GA. RESULTS: There was a significant difference in length of stay with NA patients having a shorter length of stay (NA 32.7 hours vs GA 38.1 hours, P = .003). Patients receiving NA had significantly lower PACU morphine milligram equivalents (MME) (NA 10.2 MME vs GA 15.6 MME, P < .001) and reported a lower score on the PACU pain numeric rating scale (NA 2.1 vs GA 3.7, P < .001). CONCLUSION: Neuraxial anesthesia is associated with decreased LOS, decreased PACU MME, and a lower PACU pain score for patients undergoing primary DA THA. These trends remained consistent when controlling for age, gender, BMI, and ASA.
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Artroplastia de Reemplazo de Cadera , Anestesia General/efectos adversos , Artroplastia de Reemplazo de Cadera/efectos adversos , Humanos , Tiempo de Internación , Dolor , Manejo del Dolor , Estudios RetrospectivosRESUMEN
BACKGROUND: The Covid-19 pandemic threatens to overwhelm scarce clinical resources. Risk factors for severe illness must be identified to make efficient resource allocations. OBJECTIVE: To evaluate risk factors for severe illness. DESIGN: Retrospective, observational case series. SETTING: Single-institution. PARTICIPANTS: First 117 consecutive patients hospitalized for Covid-19 from March 1 to April 12, 2020. EXPOSURE: None. MAIN OUTCOMES AND MEASURES: Intensive care unit admission or death. RESULTS: In-hospital mortality was 24.8% and average total length of stay was 11.82 days (95% CI: 10.01 to 13.63 days). 30.8% of patients required intensive care unit admission and 29.1% required mechanical ventilation. Multivariate regression identified the amount of supplemental oxygen required at admission (OR: 1.208, 95% CI: 1.011-1.443, p = .037), sputum production (OR: 6.734, 95% CI: 1.630-27.812, p = .008), insulin dependent diabetes mellitus (OR: 11.873, 95% CI: 2.218-63.555, p = .004) and chronic kidney disease (OR: 4.793, 95% CI: 1.528-15.037, p = .007) as significant risk factors for intensive care unit admission or death. Of the 48 patients who were admitted to the intensive care unit or died, this occurred within 3 days of arrival in 42%, within 6 days in 71%, and within 9 days in 88% of patients. CONCLUSIONS: At our regional medical center, patients with Covid-19 had an average length of stay just under 12 days, required ICU care in 31% of cases, and had a 25% mortality rate. Patients with increased sputum production and higher supplemental oxygen requirements at admission, and insulin dependent diabetes or chronic kidney disease may be at increased risk for severe illness. A model for predicting intensive care unit admission or death with excellent discrimination was created that may aid in treatment decisions and resource allocation. Early identification of patients at increased risk for severe illness may lead to improved outcomes in patients hospitalized with Covid-19.
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Betacoronavirus/genética , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/patología , Hospitalización , Neumonía Viral/epidemiología , Neumonía Viral/patología , Anciano , Anciano de 80 o más Años , COVID-19 , Infecciones por Coronavirus/mortalidad , Infecciones por Coronavirus/virología , Enfermedad Crítica , Femenino , Asignación de Recursos para la Atención de Salud , Mortalidad Hospitalaria , Hospitales Comunitarios , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Maryland/epidemiología , Persona de Mediana Edad , Pandemias , Neumonía Viral/mortalidad , Neumonía Viral/virología , Respiración Artificial , Estudios Retrospectivos , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Factores de Riesgo , SARS-CoV-2RESUMEN
BACKGROUND: Patients and healthcare systems are increasingly focused on evaluating interventions that increase the value of care delivered. Our objective of this study is to evaluate early post-operative outcomes among those patients who underwent total joint arthroplasty with and without the participation in our piloted Outpatient Physical Therapy Home Visits (OPTHV) program. METHODS: A retrospective analysis of patients undergoing total hip arthroplasty and total knee arthroplasty at a single institution from July 2016 to September 2017 was performed. Matched cohorts were compared according to OPTHV enrollment status. RESULTS: In total, 1729 patients were included in this study. Two hundred ninety-three patients were enrolled in OPTHV, while 1436 patients received institutional standard care. Patients were matched by gender (56.7% vs 57.7% female, P = .751), age (67.75 vs 66.95 years, P = .167), body mass index (30.18 vs 30.12 kg/m2, P = .859), and average American Society of Anesthesiologists score (2.31 vs 2.36, P = .131). OPTHV patients had a shorter length of stay (1.39 vs 1.64 days, P < .001) and were more likely to discharge to home (89.8% vs 74.7%, P < .001). Ninety-day re-admissions (2.7% vs 2.6%, P = .880) and emergency room visits (4.1% vs 4.3%, P = .864) were equivalent. CONCLUSION: OPTHV is a novel program that facilitates discharge home and decreased length of stay after total joint arthroplasty without increasing re-admissions or emergency room visits. Utilization of OPTHV may contribute toward reducing the episode of care costs by reducing utilization of skilled nursing facility and home health services. Further prospective studies are needed to evaluate the effect of OPTHV on the total cost of care and functional outcomes.