RESUMEN
Publication of 2 (negative) randomized clinical trials (RCTs) in 2002 and 2008 demonstrating inefficacy of arthroscopic debridement of the knee (ADK) for osteoarthritis, and a 2004 national non-coverage Medicare determination, have decreased overall ADK utilization. However, because of potentially favorable outcomes associated with high volume, surgeons performing high arthroscopy volume may be slower to abandon performing ADK than would low volume surgeons. We examined the trends in ADKs performed by high and low volume surgeons before and after these 2 trials and the Medicare determination. New York state residents 40 years and older undergoing outpatient ADK from 1997 to 2010 were identified from a statewide database, and monthly population-based age and sex-adjusted ADK rates were calculated. We estimated the change in utilization trends over time, stratified by surgeon annual arthroscopy volume, for Medicare and non-Medicare patients. 1386 surgeons performed 29,658 ADKs during the study period, with the proportion performed by high volume surgeons increasing from 22% in 1997 to 66% in 2010. Overall monthly ADK rates declined from 2.4 to 1.3 per 100,000 population (45%) over the study period. Rates of ADK performed by high volume surgeons increased after the first RCT in the non-Medicare population and after the CMS decision in the Medicare population, and decreased after the second RCT. With more definitive evidence from the second negative trial, high volume surgeons performed less ADKs, suggesting that multiple RCTs with consistently negative results are needed to change practice of high volume surgeons.
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BACKGROUND: The rate of cervical spinal fusion has been increasing significantly. However, there is a paucity of literature describing trends based on surgical approach using complete population databases. We investigated the approach-based trends in epidemiology, indications, and in-hospital outcomes of cervical spinal fusion. METHODS: New York's Statewide Planning and Research Cooperative System database was queried to identify patients who underwent primary subaxial cervical fusion from 1997 to 2012. Demographic and clinical information was obtained. Subgroup analyses were performed based on surgical approach: anterior (A), posterior (P), and circumferential (C). RESULTS: A total of 87,045 cervical fusions were included. Over the study period, the population-adjusted annual fusion rate increased from 23.7 to 50.6 per 100,000 population (P < 0.001). A fusion was most common (85.2%), followed by P (12.3%), and C (2.5%). Mean ages were 49.8 ± 11.9, 59.9 ± 15.2, and 55.1 ± 14.5 years (P < 0.001), respectively. Although rates remained steady among younger patients, they increased for older patients. Overall, degenerative conditions were the predominant indications for surgery and increased in rate over time. The mean length of stay was: A, 3.1 ± 10.5; P, 9.1 ± 14.1; and C, 14.1 ± 22.5 days (P < 0.001). Rates of in-hospital complications were A, 3.0%; P, 10.5%; and C, 18.9% (P < 0.001), and mortality was A, 0.3%, P, 1.8%, and C, 2.5% (P < 0.001). CONCLUSIONS: The rate of subaxial spinal fusions increased 114% from 1997 to 2012 in New York State. Rates remained stable in younger patients but increased in the older population. Preoperative indications and postoperative courses differed significantly among the various approaches, with patients undergoing anterior fusion having better short-term outcomes.
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Vértebras Cervicales/cirugía , Enfermedades de la Columna Vertebral/cirugía , Fusión Vertebral/tendencias , Adulto , Anciano , Comorbilidad , Grupos Diagnósticos Relacionados , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Enfermedades de la Columna Vertebral/epidemiología , Fusión Vertebral/métodos , Fusión Vertebral/estadística & datos numéricos , Resultado del TratamientoRESUMEN
STUDY DESIGN: Retrospective state database analysis. OBJECTIVE: To quantify the 30- and 90-day emergency department (ED) utilization and inpatient readmission rates after primary cervical arthrodesis, to stratify these findings by surgical approach, and to describe risk factors and conditions precipitating these events. SUMMARY OF BACKGROUND DATA: Limited data exist on ED utilization and hospital readmission rates after cervical spine arthrodesis. METHODS: The New York State all-payer health-care database was queried to identify all 87,045 patients who underwent primary subaxial cervical arthrodesis from 1997 through 2012. Demographic data and clinical information were extracted. Readmission data were available for the entire study period, whereas ED utilization data collection began later and was therefore analyzed starting in 2005. Incidences of these events within 30 and 90 days of discharge as well as trends over time were tabulated. The conditions prompting these encounters were also collected. Data were analyzed with respect to surgical approach. RESULTS: The hospital readmission rate was 4.2% at 30 days and 6.2% at 90 days postoperatively. Approximately 6.2% of patients were managed in the ED without inpatient admission within 30 days and 11.3% within 90 days of surgery. The most common conditions prompting such events were dysphagia or dysphonia, respiratory complications, and infection. ED utilization and readmission rates were lowest after anterior surgeries. A preoperative Charlson Comorbidity Index of 1 or greater and traumatic pathologies were associated with increased risk of subsequent ED utilization or hospital readmission. Thirty-day hospital readmission rates declined after 2010, whereas 30-day ED utilization continued to increase. CONCLUSION: Patient comorbidities, traumatic pathologies, and surgical approach are associated with increased postoperative complications. Anterior procedures carry the lowest risk, followed by posterior and then circumferential. Awareness of these findings should help to encourage development of strategies to minimize the rate of postoperative ED utilization and hospital readmission. LEVEL OF EVIDENCE: 3.
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Vértebras Cervicales/cirugía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Enfermedades de la Columna Vertebral/cirugía , Fusión Vertebral/efectos adversos , Adulto , Anciano , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Alta del Paciente , Complicaciones Posoperatorias/etiología , Periodo Posoperatorio , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Increasing evidence supports the finding that patients undergoing a total knee arthroplasty with high-volume physicians and hospitals achieve better outcomes. Unfortunately, the existing definitions for high-volume surgeons and hospitals are highly variable and entirely arbitrary. The aim of this study was to identify a set of meaningful hospital and surgeon total knee arthroplasty volume thresholds. METHODS: Using 289,976 patients undergoing primary total knee arthroplasty from an administrative database, we applied stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate sets of volume thresholds most predictive of adverse outcomes. The outcomes considered for surgeon volume included 90-day complication and 2-year revision. For hospital volume, we considered 90-day complications and 90-day mortality. RESULTS: SSLR analysis of the ROC curves for 90-day complication and 2-year revision rates by surgeon volume identified four volume categories: 0 to 12, 13 to 59, 60 to 145, and ≥146 total knee arthroplasties per year. Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories. Revision rates followed a similar pattern, but did not decrease between surgeons performing 60 to 145 arthroplasties per year and those performing ≥146 arthroplasties per year. SSLR analysis of 90-day complication and 90-day mortality rates by hospital volume also identified four volume categories: 0 to 89, 90 to 235, 236 to 644, and ≥645 total knee arthroplasties per year. Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories, but the rates did not decrease between hospitals performing 236 to 644 arthroplasties per year and those performing ≥645 arthroplasties per year. Mortality rates for hospitals with ≥645 total knee arthroplasties per year were significantly lower (p < 0.05) than those below the threshold. CONCLUSIONS: Our study supports the use of SSLR analysis of ROC curves for risk-based volume stratification in total knee arthroplasty volume-outcomes research. SSLR analysis established meaningful volume definitions for low, medium, high, and very high-volume total knee arthroplasty surgeons and hospitals. This should help patients, surgeons, hospitals, and policymakers to make decisions with regard to the optimal delivery of total knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Artroplastia de Reemplazo de Rodilla/efectos adversos , Complicaciones Posoperatorias/epidemiología , Reoperación/estadística & datos numéricos , Anciano , Artroplastia de Reemplazo de Rodilla/métodos , Bases de Datos Factuales , Femenino , Hospitales de Alto Volumen , Humanos , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Falla de Prótesis , Resultado del TratamientoRESUMEN
BACKGROUND: Limited data exist on long-term revision rates following cervical spine arthrodeses. The purposes of this study were to define reoperation rates after primary cervical arthrodeses and to identify risk factors for revisions. METHODS: New York State's all-payer health-care database was queried to identify all primary subaxial cervical arthrodeses occurring in the 16 years from 1997 through 2012. A total of 87,042 patients were included in the study cohort. Demographic information was extracted. Patients' preoperative medical comorbidities, surgical indications, and operative approaches were assembled using codes from the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification). The cohort was followed to revision surgical procedures, death, or the end of the study period. All subsequent contiguous spinal arthrodeses, including in the subaxial cervical spine, were considered revisions. The overall revision risk and the risk associated with various preoperative characteristics, surgical indications, and operative approaches were assessed using a Cox proportional hazard model. RESULTS: During the study period, 6,721 patients (7.7%) underwent revision. The median time to revision was 24.5 months. The probability of undergoing at least one revision by 192 months was 12.6%. Arthrodeses performed via anterior-only approaches had a significantly higher probability of revision (p < 0.001) at 13.4% (95% confidence interval [95% CI], 12.9% to 13.9%) than those performed via posterior approaches at 7.4% (95% CI, 6.6% to 8.4%) or circumferential (anterior and posterior) approaches at 5.2% (95% CI, 4.0% to 6.8%). This relationship persisted in multivariate analysis; compared with anterior surgical procedures, there was a significantly lower risk of revision (p < 0.001) for posterior surgical approaches at a hazard ratio of 0.76 (95% CI, 0.69 to 0.84) and circumferential approaches at a hazard ratio of 0.53 (95% CI, 0.42 to 0.66). Patient age of 18 to 34 years, white race, insurance status of Workers' Compensation or Medicare, and surgical procedures for spinal stenosis, spondylosis, deformity, and neoplasm were associated with elevated revision risk. Arthrodeses spanning few levels and those performed for fractures had a lower revision risk. CONCLUSIONS: Primary subaxial cervical spine arthrodeses had a probability of revision approaching 13% over a 16-year period, with elevated reoperation rates in patients undergoing anterior-only surgical procedures. Age, race, insurance status, surgical indication, and number of spinal levels included in the arthrodesis were also associated with reoperation risk. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Vértebras Cervicales/cirugía , Fusión Vertebral/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Bases de Datos Factuales , Femenino , Humanos , Degeneración del Disco Intervertebral/cirugía , Masculino , Medicare , Persona de Mediana Edad , New York , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Fusión Vertebral/métodos , Estenosis Espinal/cirugía , Espondilosis/cirugía , Resultado del Tratamiento , Estados Unidos , Indemnización para Trabajadores , Adulto JovenRESUMEN
BACKGROUND: Previous studies of racial disparities in total joint replacement, particularly total knee arthroplasty, in the U.S. have predominantly focused on disparities between blacks and whites and were limited to Medicare patients or veterans, populations that are not representative of the entire U.S. POPULATION: We sought to study racial disparities in the utilization of total knee arthroplasty, the use of high-volume hospitals, and total knee arthroplasty outcomes, including mortality and complications, using all-payer databases. METHODS: We analyzed data from 8 years and 8 racially diverse states in the State Inpatient Databases (SID). Patient race was categorized according to the SID as white, black, Hispanic, Asian, Native American, and mixed race. Both crude and adjusted racial and/or ethnic disparities were evaluated. RESULTS: In comparison with whites (4.65 per 1000 population per year), black (3.90), Hispanic (3.71), Asian (3.89), Native American (4.40), and mixed-race (3.69) populations had lower rates of total knee arthroplasty utilization (p < 0.0001). After risk adjustment, the rate of total knee arthroplasty utilization was significantly lower for blacks (odds ratio [OR] = 0.87 [95% confidence interval (CI), 0.85 to 0.89]; p < 0.0001), Hispanics (OR = 0.76 [95% CI, 0.68 to 0.83]; p < 0.0001), Asians (OR = 0.83 [95% CI, 0.78 to 0.89]; p < 0.0001), Native Americans (OR = 0.87 [95% CI, 0.81 to 0.93]; p < 0.0001), and mixed race (OR = 0.84 [95% CI, 0.79 to 0.90]; p < 0.0001) compared with the rate for whites. Lower rates of total knee arthroplasty utilization for blacks, Hispanics, and mixed-race groups became worse over the years. Patients from minority groups were less likely to undergo total knee arthroplasty in high-volume hospitals than were whites. Moreover, the rates of mortality were significantly higher for blacks (OR = 1.52 [95% CI, 1.17 to 1.97]; p = 0.0017), Native Americans (OR = 6.52 [95% CI, 4.63 to 9.17]; p < 0.0001), and mixed-race patients (OR = 4.35 [95% CI, 3.24 to 5.84]; p < 0.0001). Blacks (OR = 1.08 [95% CI, 1.01 to 1.15]; p = 0.01) and mixed-race patients (OR = 1.17 [95% CI, 1.001 to 1.36]; p = 0.04) had higher rates of complications than whites. CONCLUSIONS: Minorities had lower rates of total knee arthroplasty utilization but higher rates of adverse health outcomes associated with the procedure, even after adjusting for patient-related and health-care system-related characteristics. Utilization rates were based on overall population as the proportion of the population with osteoarthritis requiring arthroplasty is unknown. Future studies that consider specific patient-level information with psychosocial and behavioral factors are needed. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Accesibilidad a los Servicios de Salud , Disparidades en el Estado de Salud , Disparidades en Atención de Salud/etnología , Complicaciones Posoperatorias/etnología , Negro o Afroamericano , Anciano , Anciano de 80 o más Años , Femenino , Hispánicos o Latinos , Hospitales de Alto Volumen , Humanos , Indígenas Norteamericanos , Masculino , Medicare , Persona de Mediana Edad , Osteoartritis/cirugía , Resultado del Tratamiento , Estados Unidos , Población BlancaRESUMEN
BACKGROUND: Despite declines in both the incidence of and mortality following hip fracture, there are racial and socioeconomic disparities in treatment access and outcomes. We evaluated the presence and implications of disparities in delivery of care, hypothesizing that race and community socioeconomic characteristics would influence quality of care for patients with a hip fracture. METHODS: We collected data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS), which prospectively captures information on all discharges from nonfederal acute-care hospitals in New York State. Records for 197,290 New York State residents who underwent surgery for a hip fracture between 1998 and 2010 in New York State were identified from SPARCS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multivariable regression models were used to evaluate the association of patient characteristics, social deprivation, and hospital/surgeon volume with time from admission to surgery, in-hospital complications, readmission, and 1-year mortality. RESULTS: After adjusting for patient and surgery characteristics, hospital/surgeon volume, social deprivation, and other variables, black patients were at greater risk for delayed surgery (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.42, 1.57), a reoperation (hazard ratio [HR] = 1.21; CI = 1.11, 1.32), readmission (OR = 1.17; CI = 1.11, 1.22), and 1-year mortality (HR = 1.13; CI = 1.07, 1.21) than white patients. Subgroup analyses showed a greater risk for delayed surgery for black and Asian patients compared with white patients, regardless of social deprivation. Additionally, there was a greater risk for readmission for black patients compared with white patients, regardless of social deprivation. Compared with Medicare patients, Medicaid patients were at increased risk for delayed surgery (OR = 1.17; CI = 1.10, 1.24) whereas privately insured patients were at decreased risk for delayed surgery (OR = 0.77; CI = 0.74, 0.81), readmission (OR = 0.77; CI = 0.74, 0.81), complications (OR = 0.80; CI = 0.77, 0.84), and 1-year mortality (HR = 0.80; CI = 0.75, 0.85). CONCLUSIONS: There are race and insurance-based disparities in delivery of care for patients with hip fracture, some of which persist after adjusting for social deprivation. In addition to investigation into reasons contributing to disparities, targeted interventions should be developed to mitigate effects of disparities on patients at greatest risk. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Disparidades en Atención de Salud/estadística & datos numéricos , Fracturas de Cadera/epidemiología , Seguro de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Pueblo Asiatico/estadística & datos numéricos , Población Negra/estadística & datos numéricos , Atención a la Salud/etnología , Atención a la Salud/estadística & datos numéricos , Femenino , Disparidades en Atención de Salud/etnología , Fracturas de Cadera/complicaciones , Mortalidad Hospitalaria/etnología , Humanos , Masculino , Medicaid/estadística & datos numéricos , Medicare/estadística & datos numéricos , New York/epidemiología , Readmisión del Paciente/estadística & datos numéricos , Calidad de la Atención de Salud/estadística & datos numéricos , Reoperación/estadística & datos numéricos , Factores de Riesgo , Factores Socioeconómicos , Factores de Tiempo , Estados Unidos/epidemiología , Población Blanca/estadística & datos numéricosRESUMEN
STUDY DESIGN: A retrospective state database analysis. OBJECTIVE: The aim of this study was to describe the epidemiology and complications of as well as indications for primary isolated atlantoaxial fusion. SUMMARY OF BACKGROUND DATA: Atlantoaxial fusion involves unique indications, techniques, and complications. There is limited epidemiologic literature focused specifically on this procedure. METHODS: New York's Statewide Planning and Research Cooperative System database, an all-payer hospitalization reporting system, was queried to identify all patients undergoing primary isolated atlantoaxial fusion in the state from 1997 to 2012. Demographic and clinical data were extracted and analyzed. United States Census Bureau figures were used to calculate population-adjusted surgical rates. RESULTS: One thousand five hundred fifty-nine patients underwent isolated primary atlantoaxial fusion during the study period. The overall population-adjusted annual surgical rate did not change significantly over time. By 2012, individuals aged ≥70 years had the highest incidence of surgery [2.37 per 100,000 population; 95% confidence interval (95% CI) 1.68-3.07]. Medicare was the most common payer (44.0% of claims). Approximately 85% of patients had a Charlson/Deyo Comorbidity Index of zero or one. Over time, a significantly lower proportion of atlantoaxial fusions were attributable to rheumatic disease, and a significantly higher proportion were due to fracture. By 2012, management of fractures was the most common indication for C1-C2 fusion (44.1% of cases). Dysphagia or dysphonia occurred after 0.8% of cases, dural tear after 0.3%, infection after 0.5%, and seroma, hematoma, or hemorrhage after 0.5%. In-hospital mortality was 2.7%, of which 76% had fracture as the surgical indication. CONCLUSION: Isolated atlantoaxial fusions have been performed at a stable, low level over the past 16 years in New York. Although most of these patients are relatively healthy pre-operatively, approximately one in 10 experience an in-hospital complication and nearly 3% die in-hospital. Knowledge of these risks will hopefully spur further efforts to minimize them and allow for more accurate counseling of patients and their families. LEVEL OF EVIDENCE: 4.
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Articulación Atlantoaxoidea/cirugía , Fracturas de la Columna Vertebral/cirugía , Fusión Vertebral/efectos adversos , Fusión Vertebral/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Articulación Atlantoaxoidea/lesiones , Tornillos Óseos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: The goal of elective orthopedic surgery is to return patients to their expected level of activity without an increased incidence of postoperative complications. The first step is identifying patient and/or surgical characteristics responsible for these complications. QUESTIONS/PURPOSES: This study sought to identify predictors of a step-up in medical care after non-ambulatory elective orthopedic surgery. METHODS: At a single specialty orthopedic hospital, we identified all in-hospital postoperative patients who were transferred to a higher level of medical care ((PACU) post-anesthesia care unit). The characteristics of both transferred and non-transferred patients were compared. A model was built which incorporated predictors of return to a higher level of care. RESULTS: During a 1-year period, 155 of 7967 patients (1.95%) required transfer to the PACU within 5 days of surgery. Cardiac complications were the major reason for transfer (50.3%), followed by pulmonary (11.0%) and neurological complications (9.7%). Patients who returned to the PACU were older, had more Exlihauser comorbidities, and had obstructive sleep apnea (OSA). In a model adjusting for all patient characteristics: age, American Society of Anesthesiologists (ASA) status, congestive heart failure (CHF), the Charlson comorbidity index and OSA predicted return to the PACU. CONCLUSIONS: In an elderly population with multiple comorbidities undergoing elective common major orthopedic procedures, approximately 2% of patients required readmission to the PACU. The most common problems requiring this step-up in care were cardiac and pulmonary, which resulted in an increased length of hospital stay. Patients with OSA and multiple comorbidities undergoing total knee arthroplasty carry an increased risk for postoperative complications.
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BACKGROUND: Disparities exist in access to outpatient pediatric orthopaedic care. The purpose of this study was to assess whether disparities also exist in elective pediatric orthopaedic surgical procedures such as implant removal, and to determine which demographic and socioeconomic factors may be associated with differences in treatment. METHODS: Children aged 7 to 18 inclusive who sustained femoral shaft fractures between the years 1997 and 2010 were identified in the New York State SPARCS database. Patient age, sex, race/ethnicity, insurance status, education, and poverty were identified. Factors associated with the method of fracture treatment were assessed through multivariate regression analysis. The subset of patients that received internal fixation were followed up until 2011 inclusive for implant removal. Factors associated with implant removal were assessed using a Cox proportional hazards survival analysis (time to implant removal). RESULTS: Of the 3220 closed femoral shaft fractures identified, 2609 (81%) were treated with internal fixation, 9 (0.3%) had open treatment without implants, 203 (6.3%) were treated with external fixation, and 399 (12.4%) with closed methods. Patients with No Fault/Accident insurance by No Fault/Accident insurance were more likely to undergo internal fixation compared with patients with private insurance (P<0.001). Of the 3220 patients, 2572 were included in the implant removal subanalysis. Implant removal was performed in 725 (28.2%) patients. In the multivariate model, patients were more likely to undergo removal if they were younger (P<0.001), white [vs. black (P<0.001), vs. Hispanic (P=0.035), vs. other (P=0.001)], and lived in neighborhoods with less poverty (P=0.016). Insurance status was not a statistically significant predictor of implant removal. CONCLUSIONS: There is an association between implant removal and younger age, white race, and higher socioeconomic status in children. Awareness of these disparities should prompt further evaluation of causation, whether it be from lack of evidence-based guidelines for implant removal, surgeon bias, variations in reimbursement, or disparities in access to care. Further study is recommended to better elucidate the indications for implant removal in children and the causes for the disparities identified here. LEVEL OF EVIDENCE: Level III-retrospective cohort study.
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Remoción de Dispositivos/estadística & datos numéricos , Etnicidad/estadística & datos numéricos , Fracturas del Fémur/terapia , Fémur/cirugía , Fijación Interna de Fracturas/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Pobreza/estadística & datos numéricos , Clase Social , Adolescente , Negro o Afroamericano/estadística & datos numéricos , Placas Óseas , Niño , Reducción Cerrada/estadística & datos numéricos , Femenino , Fijación de Fractura/métodos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/etnología , Disparidades en Atención de Salud/estadística & datos numéricos , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Cobertura del Seguro , Masculino , Análisis Multivariante , New York , Reducción Abierta/estadística & datos numéricos , Modelos de Riesgos Proporcionales , Análisis de Regresión , Estudios Retrospectivos , Factores Socioeconómicos , Población Blanca/estadística & datos numéricosRESUMEN
Regionalization of total joint arthroplasty (TJA) to high volume hospitals (HVHs) may affect access to care and complication risk. Using administrative data, 2,560,314 patients who underwent primary total hip or knee arthroplasty from 1991 to 2006 were categorized by whether an HVH (>200 annual TJAs) was available locally. Associations among patient characteristics, hospital utilization, and in-hospital complications were estimated using regression modeling. The complication risk was higher (Odds Ratio 1.18 [95% CI: 1.16, 1.20]) if patients went to a local low volume hospital. Black and Medicaid patients were more likely to utilize the local low volume hospital than a local HVH. Utilizing a local HVH is associated with lower complication risks. However, patients from vulnerable groups were less likely to utilize these patterns.
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Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Atención a la Salud/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Hospitales de Alto Volumen/estadística & datos numéricos , Negro o Afroamericano/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Humanos , Masculino , Medicaid/estadística & datos numéricos , Persona de Mediana Edad , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To evaluate population-based systemic lupus erythematosus (SLE) arthroplasty rates and compare them with rates in patients with no inflammatory or autoimmune conditions. METHODS: Administrative hospital discharge databases from 10 American states were used to compare knee, hip, and shoulder arthroplasty rates from 1991 to 2005 in patients with SLE and in patients with no inflammatory or autoimmune conditions. RESULTS: Arthroplasties were performed on patients with SLE (n = 4253) and patients with noninflammatory conditions (n = 2,762,660). Arthroplasty rates for patients with noninflammatory conditions almost doubled from 1991 to 2005 (124.5 cases/100,000 persons vs 247.5/100,000; p < 0.001). A similar trend was observed for SLE (0.17/100,000 vs 0.38/100,000; p < 0.001). The mean age at arthroplasty in patients with noninflammatory conditions decreased (71.5 ± 11.8 vs 69.0 ± 12.0; p < 0.001), whereas the mean age in patients with SLE increased (47.3 ± 17.0 vs 56.8 ± 16.0; p < 0.001). When stratified by age and sex, arthroplasty in cases of SLE increased in all groups except for women < 44 years old. In 1991, osteonecrosis accounted for 53% and osteoarthritis (OA) 23% of cases of SLE; by 2005 this relationship had reversed, with osteonecrosis accounting for 24% and OA 61% of cases of SLE. CONCLUSION: From 1991 to 2005, arthroplasty rates increased in patients with SLE in similar proportions to overall joint replacement rates. The age of patients with SLE arthroplasty increased and fewer cases were due to osteonecrosis. These data suggest significant changes are occurring - patients with SLE are now living long enough to develop OA and are healthy enough to undergo elective surgery.
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Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Lupus Eritematoso Sistémico/epidemiología , Lupus Eritematoso Sistémico/cirugía , Adulto , Anciano , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis de la Cadera/epidemiología , Osteoartritis de la Cadera/cirugía , Osteoartritis de la Rodilla/epidemiología , Osteoartritis de la Rodilla/cirugía , Osteonecrosis/epidemiología , Osteonecrosis/cirugía , Alta del Paciente/estadística & datos numéricos , Articulación del Hombro/cirugía , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Many patients change hospitals for revision total joint arthroplasty (TJA). The implications of changing hospitals must be better understood to inform appropriate utilization strategies. QUESTIONS/PURPOSES: (1) How frequently do patients change hospitals for revision TJA? (2) Which patient, community, and hospital characteristics are associated with changing hospitals? (3) Is there an increased complication risk after changing hospitals? METHODS: We identified 17,018 patients who underwent primary TJA and subsequent same-joint revision in New York or California (1997-2005) from statewide databases. Medicare was the most common payer (56%) followed by private insurance (31%). We identified patients who changed hospitals for revision TJA and those who experienced in-hospital complications. Patient, community, and hospital characteristics were analyzed to determine predictors for changing hospitals for revision TJA and the effect of changing hospitals on subsequent complications. RESULTS: Thirty percent of patients changed hospitals for revision. Older patients were less likely to change hospitals (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.73-0.96); no other patient characteristics were associated with changing hospitals. Patients who had index TJA at the highest-volume hospitals were less likely to change hospitals (OR, 0.52; 95% CI, 0.48-0.57). Overall, changing hospitals was associated with higher complication risk (OR, 1.19; 95% CI, 1.03-1.39). Changing to a lower-volume hospital (6% of patients undergoing revision TJA) was associated with a higher risk of complications (OR, 1.36; 95% CI, 1.05-1.74). A post hoc number needed-to-treat analysis indicates that 234 patients would need to be moved from a lower volume hospital to a higher volume hospital to avoid one overall complication event after revision TJA. CONCLUSIONS: Although the complication risk was higher if changing hospitals, this finding was sensitive to the type of change. Our findings build on the existing evidence of a volume-outcomes benefit for revision TJA by examining the effect of volume in view of potential patient migration. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Artroplastia de Reemplazo/efectos adversos , Hospitalización , Hospitales de Alto Volumen , Hospitales de Bajo Volumen , Complicaciones Posoperatorias/cirugía , Factores de Edad , Anciano , Artroplastia de Reemplazo/economía , Artroplastia de Reemplazo/tendencias , Distribución de Chi-Cuadrado , Femenino , Accesibilidad a los Servicios de Salud , Costos de Hospital , Hospitalización/economía , Hospitalización/tendencias , Hospitales de Alto Volumen/tendencias , Hospitales de Bajo Volumen/tendencias , Humanos , Masculino , Medicare , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Readmisión del Paciente , Complicaciones Posoperatorias/economía , Sector Privado , Derivación y Consulta , Reoperación , Características de la Residencia , Medición de Riesgo , Factores de Riesgo , Estados UnidosRESUMEN
OBJECTIVE: Although rates of arthroplasty have increased dramatically, rates among patients with rheumatoid arthritis (RA) are reported to be decreasing. It is not known if this is also the case among patients with other inflammatory arthritides. This study was undertaken to evaluate rates of arthroplasty due to RA, juvenile idiopathic arthritis (JIA), spondyloarthritis (SpA), and a composite group of patients with inflammatory arthritides (IA), compared to arthroplasty rates among patients without inflammatory or autoimmune conditions. METHODS: Administrative discharge databases (State Inpatient Databases of the Healthcare Cost and Utilization Project, New York Department of Health Statewide Planning and Research Cooperative System, California Statewide Health Planning and Development) were used to compare rates of knee, hip, and shoulder arthroplasty occurring from 1991 to 2005. RESULTS: Of 2,839,325 arthroplasties in 1991-2005, 2.7% were performed in patients with IA. The rate of arthroplasty for noninflammatory conditions doubled (124.5 per 100,000 persons in 1991 versus 247.5 per 100,000 persons in 2005), while the rate for IA remained stable at 5.1 per 100,000. Rates of arthroplasty for RA decreased slightly (4.6 per 100,000 versus 4.5 per 100,000) and those for JIA decreased by nearly 50% (0.22 per 100,000 versus 0.13 per 100,000), but the rate of arthroplasty for SpA increased by nearly 50% (0.22 per 100,000 versus 0.31 per 100,000). Age at the time of arthroplasty increased for patients with RA (mean ± SD 63.4 ± 12.7 years versus 64.9 ± 12.8 years), JIA (30.9 ± 12.2 years versus 36.7 ± 14.9 years), and SpA (54.3 ± 16.1 years versus 60.4 ± 13.9 years). However, the mean age at the time of arthroplasty among non-IA cases decreased (71.5 ± 11.8 years versus 69.0 ± 12.0 years). CONCLUSION: This population-based study is the first to show that arthroplasty rates have decreased significantly among patients with JIA and minimally among patients with RA, and have increased among patients with SpA. The increased age at the time of arthroplasty among patients with JIA and SpA suggests that these patients are increasingly able to defer surgical interventions. Further research is needed to assess the ongoing effect of biologic agents on the need for arthroplasties in patients with IA.
Asunto(s)
Artritis Juvenil/cirugía , Artritis Reumatoide/cirugía , Artroplastia/estadística & datos numéricos , Artroplastia/tendencias , Espondiloartritis/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Artroplastia de Reemplazo de Cadera/tendencias , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/tendencias , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Hombro/cirugía , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: There have been no population-based studies to evaluate the rate of pediatric anterior cruciate ligament (ACL) reconstruction. PURPOSE: The primary aim of the current study was to determine the yearly rate of ACL reconstruction over the past 20 years in New York State. Secondary aims were to determine the age distribution for ACL reconstruction and determine whether patient demographic and socioeconomic factors were associated with ACL reconstruction. STUDY DESIGN: Descriptive epidemiology study. METHODS: The Statewide Planning and Research Cooperative System (SPARCS) database contains a census of all hospital admissions and ambulatory surgery in New York State. This database was used to identify pediatric ACL reconstructions between 1990 and 2009; ICD-9-CM (International Classification of Diseases, 9 Revision, Clinical Modification) and CPT-4 (Current Procedural Terminology, 4th Revision) codes were used to identify reconstructions. Patient sex, age, race, family income, education, and insurance status were assessed. RESULTS: The rate of ACL reconstruction per 100,000 population aged 3 to 20 years has been increasing steadily over the past 20 years, from 17.6 (95% confidence interval [CI], 16.4-18.9) in 1990 to 50.9 (95% CI, 48.8-53.0) in 2009. The peak age for ACL reconstruction in 2009 was 17 years, at a rate of 176.7 (95% CI, 160.9-192.5). In 2009, the youngest age at which ACL reconstruction was performed was 9 years. The rate of ACL reconstruction in male patients was about 15% higher than in females, and ACL reconstruction was 6-fold more common in patients with private health insurance compared with those enrolled in Medicaid. CONCLUSION: This study is the first to quantify the increasing rate of ACL reconstructions in the skeletally immature. Only ACL reconstructions were assessed, and it is possible that some ACL tears in children are not diagnosed or are treated nonoperatively. The rate of ACL tears in New York State is likely higher than the rate of reconstructions reported in this study. SIGNIFICANCE: This study quantifies the increasing rate of ACL reconstruction in the skeletally immature and suggests that there may be some disparities in care based on insurance status.
Asunto(s)
Reconstrucción del Ligamento Cruzado Anterior/estadística & datos numéricos , Adolescente , Distribución por Edad , Reconstrucción del Ligamento Cruzado Anterior/tendencias , Niño , Bases de Datos Factuales , Femenino , Humanos , Seguro de Salud/estadística & datos numéricos , Masculino , Medicaid/estadística & datos numéricos , New York , Distribución por Sexo , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: An in-depth understanding of risk factors for revision TKA is needed to minimize the burden of revision surgery. Previous studies indicate that hospital and community characteristics may influence outcomes after TKA, but a detailed investigation in a diverse population is warranted to identify opportunities for quality improvement. QUESTIONS/PURPOSES: We asked: (1) What is the frequency of revision TKA within 10 years of primary arthroplasty? (2) Which patient demographic factors are associated with revision within 10 years of TKA? (3) Which community and institutional characteristics are associated with revision within 10 years of TKA? METHODS: We identified 301,955 patients who underwent primary TKAs in New York or California from 1997 to 2005 from statewide databases. Identifier codes were used to determine whether they underwent revision TKA. Patient, community, and hospital characteristics were analyzed using multivariable regression modeling to determine predictors for revision. RESULTS: The frequency of revision was 4.0% at 5 years after the index arthroplasty and 8.9% at 9-years. Patients between 50 and 75 years old had a lower risk of revision than patients younger than 50 years (hazard ratio [HR], 0.47; 95% CI, 0.44, 0.50). Black patients were at increased risk for needing revision surgery (HR, 1.39; 95% CI, 1.29, 1.49) after adjustment for insurance type, poverty level, and education. Women (HR, 0.82; 95% CI, 0.79, 0.86) and Medicare recipients (HR, 0.82; 95% CI, 0.79, 0.86) were less likely to undergo revision surgery, whereas those from the most educated (HR, 1.09; 95% CI, 1.02, 1.16) and the poorest communities (HR, 1.08; 95% CI, 1.01, 1.15) had modest increases in risk of revision. Mid-volume hospitals (200-400 annual cases) had a reduction of early revision (HR, 0.91; 95% CI, 0.83, 0.99) compared with those performing less than 200 cases annually, whereas higher-volume hospitals (greater than 400 cases) showed little effect compared with low-volume hospitals. CONCLUSIONS: Patient, community, and institutional characteristics affect the risk for revision within 10 years of index TKA. These data can be used to develop process improvement and implant surveillance strategies among high-risk patients. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Artroplastia de Reemplazo de Rodilla/efectos adversos , Articulación de la Rodilla/cirugía , Complicaciones Posoperatorias/cirugía , Factores de Edad , Anciano , Fenómenos Biomecánicos , California/epidemiología , Etnicidad , Femenino , Hospitales de Alto Volumen , Hospitales de Bajo Volumen , Humanos , Estimación de Kaplan-Meier , Articulación de la Rodilla/fisiopatología , Masculino , Persona de Mediana Edad , Análisis Multivariante , New York/epidemiología , Modelos de Riesgos Proporcionales , Reoperación , Factores de Riesgo , Factores Sexuales , Factores Socioeconómicos , Factores de TiempoRESUMEN
OBJECTIVE: Revision total hip arthroplasty (THA) is associated with increased cost, morbidity, and technical challenge compared to primary THA. A better understanding of the risk factors for early revision is needed to inform strategies to optimize patient outcomes. METHODS: A total of 207,256 patients who underwent primary THA between 1997-2005 in California and New York were identified from statewide databases. Unique patient identifiers were used to identify early revision THA (<10 years from index procedure). Patient characteristics (demographics, comorbidities, insurance type, and preoperative diagnosis), community characteristics (education level, poverty, and population density), and hospital characteristics (annual THA volume, bed size, and teaching status) were evaluated using multivariable regression to determine risk factors for early revision. RESULTS: The probabilities of undergoing early aseptic revision and early septic revision were 4% and <1% at 5 years, respectively. Women were 29% less likely than men to undergo early septic revision (P < 0.001). Patients with Medicaid and Medicare were 91% and 24%, respectively, more likely to undergo early septic revision than privately insured patients (P = 0.01 and P < 0.001, respectively). Hospitals performing <200 THAs annually had a 34% increased risk of early aseptic revision compared to hospitals performing >400 THAs annually (P < 0.001). CONCLUSION: A number of identifiable factors, including younger age, Medicaid, and low hospital volume, increase the risk of undergoing early revision THA. Patient-level characteristics distinctly affect the risk of revision within 10 years, particularly if due to infection. Our findings reinforce the need for continued investigation of the predictors of early failure following THA.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/tendencias , Factores de Edad , Anciano , Artroplastia de Reemplazo de Cadera/economía , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reoperación/efectos adversos , Reoperación/economía , Reoperación/tendencias , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Previous research suggests that a substantial percentage of meniscal repairs fail, resulting in a subsequent meniscectomy. Risk factors for failure have been investigated using small cohorts, providing ambiguous results. PURPOSE: To measure the frequency of and elucidate risk factors for subsequent meniscectomies after meniscal repair using a large study population from multiple surgical centers. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 9529 patients who underwent 9609 outpatient meniscal repairs between 2003 and 2010 were identified from a statewide database of all ambulatory surgery in New York. Patients who subsequently underwent a meniscectomy were then identified. A Cox regression analysis was used to calculate the hazard ratio and 95% confidence intervals. The model included patient age, sex, comorbidities, concomitant arthroscopic procedures, laterality of the meniscus, and surgeon's yearly meniscal repair volume. RESULTS: The overall frequency of subsequent meniscectomies was 8.9%. Patients were at a decreased risk for subsequent meniscectomies if they underwent a concomitant anterior cruciate ligament (ACL) reconstruction (P < .001). Patients undergoing isolated meniscal repairs (without concomitant ACL reconstruction) were at a decreased risk if they were older (P < .001), had a lateral meniscal injury (P = .002), or were operated on by a surgeon with a higher annual meniscal repair volume (>24 cases/year; P < .001). CONCLUSION: A meniscectomy after meniscal repair is performed infrequently, supporting the notion that repairing a meniscus is a safe and effective procedure in the long term. The risk for undergoing subsequent meniscectomies is decreased in patients undergoing a concomitant ACL reconstruction, in cases of isolated meniscal repairs for patients of older age, and in patients undergoing meniscal repair by surgeons with a high case volume.