Health Conditions and Treatment Utilization Among Older Male Veterans Incarcerated in Prisons.

BACKGROUND: More than 50,000 older male veterans incarcerated in prisons are expected to return to their communities and utilize the Veterans Health Administration (VHA) and community healthcare systems. To support the continuity of healthcare and overall successful community reentry of older incarcerated veterans, an understanding of their health profiles and treatment utilization while in correctional care is needed. OBJECTIVE: To assess the health status of older male veterans incarcerated in state prisons and explore demographic, military, and VHA-related factors associated with medical conditions, disabilities, behavioral conditions, and medical and behavioral treatment utilization. DESIGN/PARTICIPANTS: Cross-sectional observational study of 880 male veterans aged 50 + incarcerated in state prisons using data from the 2016 Bureau of Justice Statistics Survey of Prison Inmates. MAIN MEASURES: Veteran status, self-report health status, and treatment utilization since prison admission. Prevalence rates for conditions and treatment utilization were calculated. Logistic regression models were used to examine the association of characteristics with conditions and treatment utilization. KEY RESULTS: Among the 880 older male veterans in state prisons, the majority reported having a current medical condition (79.3%) or disability (61.6%), almost half had history of a mental health condition (44.5%), and more than a quarter (29%) had a substance use disorder. Compared to White veterans, Black veterans were less likely to report a disability or mental health condition. Few demographic, military, and VA-related characteristics were associated with medical or behavioral conditions or treatment utilization. CONCLUSION: Our results suggest that the VHA and community healthcare systems need to be prepared to address medical and disability conditions among the majority of older male veterans who will be leaving prison and returning to their communities. Integrated medical and behavioral healthcare delivery models may be especially important for these veterans as many did not receive behavioral health treatment while in prison.

Development of a 3-Step theory of suicide ontology to facilitate 3ST factor extraction from clinical progress notes.

OBJECTIVE: Suicide risk prediction algorithms at the Veterans Health Administration (VHA) do not include predictors based on the 3-Step Theory of suicide (3ST), which builds on hopelessness, psychological pain, connectedness, and capacity for suicide. These four factors are not available from structured fields in VHA electronic health records, but they are found in unstructured clinical text. An ontology and controlled vocabulary that maps psychosocial and behavioral terms to these factors does not exist. The objectives of this study were 1) to develop an ontology with a controlled vocabulary of terms that map onto classes that represent the 3ST factors as identified within electronic clinical progress notes, and 2) to determine the accuracy of automated extractions based on terms in the controlled vocabulary. METHODS: A team of four annotators did linguistic annotation of 30,000 clinical progress notes from 231 Veterans in VHA electronic health records who attempted suicide or who died by suicide for terms relating to the 3ST factors. Annotation involved manually assigning a label to words or phrases that indicated presence or absence of the factor (polarity). These words and phrases were entered into a controlled vocabulary that was then used by our computational system to tag 14 million clinical progress notes from Veterans who attempted or died by suicide after 2013. Tagged text was extracted and machine-labelled for presence or absence of the 3ST factors. Accuracy of these machine-labels was determined for 1000 randomly selected extractions for each factor against a ground truth created by our annotators. RESULTS: Linguistic annotation identified 8486 terms that related to 33 subclasses across the four factors and polarities. Precision of machine-labeled extractions ranged from 0.73 to 1.00 for most factor-polarity combinations, whereas recall was somewhat lower 0.65-0.91. CONCLUSION: The ontology that was developed consists of classes that represent each of the four 3ST factors, subclasses, relationships, and terms that map onto those classes which are stored in a controlled vocabulary (https://bioportal.bioontology.org/ontologies/THREE-ST). The use case that we present shows how scores based on clinical notes tagged for terms in the controlled vocabulary capture meaningful change in the 3ST factors during weeks preceding a suicidal event.

A balance focused biometric does not predict rehabilitation needs and outcomes following total knee arthroplasty.

BACKGROUND: Both length of hospital stay and discharge to a skilled nursing facility are key drivers of total knee arthroplasty (TKA)-associated spending. Identifying patients who require increased postoperative care may improve expectation setting, discharge planning, and cost reduction. Balance deficits affect patients undergoing TKA and are critical to recovery. We aimed to assess whether a device that measures preoperative balance predicts patients' rehabilitation needs and outcomes after TKA. METHODS: 40 patients indicated for primary TKA were prospectively enrolled and followed for 12 months. Demographics, KOOS-JR, and PROMIS data were collected at baseline, 3-months, and 12-months. Single-leg balance and sway velocity were assessed preoperatively with a force plate (Sparta Science, Menlo Park, CA). The primary outcome was patients' discharge facility (home versus skilled nursing facility). Secondary outcomes included length of hospital stay, KOOS-JR scores, and PROMIS scores. RESULTS: The mean preoperative sway velocity for the operative leg was 5.7 ± 2.7 cm/s, which did not differ from that of the non-operative leg (5.7 ± 2.6 cm/s, p = 1.00). Five patients (13%) were discharged to a skilled nursing facility and the mean length of hospital stay was 2.8 ± 1.5 days. Sway velocity was not associated with discharge to a skilled nursing facility (odds ratio, OR = 0.82, 95% CI = 0.27-2.11, p = 0.690) or longer length of hospital stay (b = -0.03, SE = 0.10, p = 0.738). An increased sway velocity was associated with change in PROMIS items from baseline to 3 months for global07 ("How would you rate your pain on average?" b = 1.17, SE = 0.46, p = 0.015) and pain21 ("What is your level of pain right now?" b = 0.39, SE = 0.17, p = 0.025) at 3-months. CONCLUSION: Preoperative balance deficits were associated with postoperative improvements in pain and function after TKA, but a balance focused biometric that measured single-leg sway preoperatively did not predict discharge to a skilled nursing facility or length of hospital stay after TKA making their routine measurement cost-ineffective.

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow.

PURPOSE: To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. METHODS: This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. RESULTS: Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). CONCLUSIONS: This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

Co-occurring Medical Multimorbidity, Mental Illness, and Substance Use Disorders Among Older Criminal Legal System-Involved Veterans.

BACKGROUND: Older veterans involved in the criminal legal system (CLS) may have patterns of multimorbidity that place them at risk for poor health outcomes. OBJECTIVES: To estimate the prevalence of medical multimorbidity (≥2 chronic medical diseases), substance use disorders (SUDs), and mental illness among CLS-involved veterans aged 50 and older. RESEARCH DESIGN: Using Veterans Health Administration health records, we estimated the prevalence of mental illness, SUD, medical multimorbidity, and the co-occurrence of these conditions among veterans by CLS involvement as indicated by Veterans Justice Programs encounters. Multivariable logistic regression models assessed the association between CLS involvement, the odds for each condition, and the co-occurrence of conditions. SUBJECTS: Veterans aged 50 and older who received services at Veterans Health Administration facilities in 2019 (n=4,669,447). METHODS: Mental illness, SUD, medical multimorbidity. RESULTS: An estimated 0.5% (n=24,973) of veterans aged 50 and older had CLS involvement. For individual conditions, veterans with CLS involvement had a lower prevalence of medical multimorbidity compared with veterans without but had a higher prevalence of all mental illnesses and SUDs. After adjusting for demographic factors, CLS involvement remained associated with concurrent mental illness and SUD (adjusted odds ratio [aOR] 5.52, 95% CI=5.35-5.69), SUD and medical multimorbidity (aOR=2.09, 95% CI=2.04-2.15), mental illness and medical multimorbidity (aOR=1.04, 95% CI=1.01-1.06), and having all 3 simultaneously (aOR=2.42, 95% CI=2.35-2.49). CONCLUSIONS: Older veterans involved in the CLS are at high risk for co-occurring mental illness, SUDs, and medical multimorbidity, all of which require appropriate care and treatment. Integrated care rather than disease-specific care is imperative for this population.

Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing.

BACKGROUND: Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described. OBJECTIVE: We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice. DESIGN: Qualitative study of semi-structured telephone interviews. PARTICIPANTS: We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate. APPROACH: Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations. KEY RESULTS: Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures). CONCLUSIONS: We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

Is Operative Time Associated With Obesity-related Outcomes in TKA?

BACKGROUND: Obesity-based cutoffs in TKA are premised on higher rates of postoperative complications. However, operative time may be associated with postoperative complications, leading to an unnecessary restriction of TKA in patients with obesity. If operative time is associated with these obesity-related outcomes, it should be accounted for in order to ensure all measurable factors associated with negative outcomes are examined for patients with obesity after TKA. QUESTIONS/PURPOSES: We asked: (1) Is operative time, controlling for BMI class, associated with readmission, reoperation, and postoperative major and minor complications? (2) Is operative time associated with a difference in the direction or strength of obesity-related adverse outcomes? METHODS: In this comparative study, we extracted all records on elective, unilateral TKA between January 2014 and December 2020 in the American College of Surgeons National Surgical Quality Improvement Program database, resulting in an initial sample of 394,381 TKAs. Patients with emergency procedures (0.1% [270]) and simultaneous bilateral TKAs (2% [8736]), missing or null data (1% [4834]), and those with operative times less than 25 minutes (0.1% [548]) were excluded, leaving 96% (379,993) of our original sample size. The National Surgical Quality Improvement Program database was selected because of its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight (BMI < 18.5 kg/m2, < 1% [719]), normal weight (BMI 18.5 to 24.9 kg/m2, 9% [34,513]), overweight (BMI 25.0 to 29.9 kg/m2, 27% [101,538]), Class I obesity (BMI 30.0 to 34.9 kg/m2, 29% [111,712]), Class II obesity (BMI 35.0 to 39.9 kg/m2, 20% [76,605]), and Class III obesity (BMI ≥ 40.0 kg/m2, 14% [54,906]). The mean operative time was 91 ± 36 minutes, 61% of patients were women (233,062 of 379,993), and the mean age was 67 ± 9 years. Patients with obesity tended to be younger and more likely to have preoperative comorbidities and longer operative times than patients with normal weight. Multivariable logistic regression models examined the main effects of operative time with respect to 30-day readmission, reoperation, and major and minor medical complications, while adjusting for BMI class and other covariates including age, sex, race, smoking status, and number of preoperative comorbidities. We then evaluated the potential interaction effect of BMI class and operative time. This interaction term helps determine whether the association of BMI with postoperative outcomes changes based on the duration of the surgery, and vice versa. If the interaction term is statistically significant, it implies the association of BMI with adverse postoperative outcomes is inconsistent across all patients. Instead, it varies with the operative time. Adjusted odds ratios and 95% confidence intervals were calculated, and interaction effects were plotted. RESULTS: After controlling for obesity, longer procedure duration was independently associated with higher odds of all outcomes (30-minute estimates; adjusted ORs are per minute), including readmission (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), reoperation (15% per half-hour of surgical duration; adjusted OR 1.005 [95% CI 1.004 to 1.005]; p < 0.001), postoperative major complications (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), and postoperative minor complications (18% per half-hour of surgical duration; adjusted OR 1.006 [95% CI 1.006 to 1.007]; p < 0.001). The interaction effect indicates that patients with obesity had lower odds of reoperation than patients with normal weight when operative times were shorter, but higher odds of reoperation with a longer operative duration. CONCLUSION: We found that operative time, a proxy for surgical complexity, had a moderate, differential association with obesity over a 30-minute period. Perioperative modification of surgical complexity such as surgical techniques, training, and team dynamics may make safe TKA possible for certain patients who might have otherwise been denied surgery. Decisions to refuse TKA to patients with obesity should be based on a holistic assessment of a patient's operative complexity, rather than strictly assessing a patient's weight or their ability to lose weight. Future studies should assess patient-specific characteristics that are associated with operative time, which can further push the development of techniques and strategies that reduce surgical complexity and improve TKA outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

Does Operative Time Modify Obesity-related Outcomes in THA?

BACKGROUND: Most orthopaedic surgeons refuse to perform arthroplasty on patients with morbid obesity, citing the higher rate of postoperative complications. However, that recommendation does not account for the relationship of operative time (which is often longer in patients with obesity) to obesity-related arthroplasty outcomes, such as readmission, reoperation, and postoperative complications. If operative time is associated with these obesity-related outcomes, it should be accounted for and addressed to properly assess the risk of patients with obesity undergoing THA. QUESTIONS/PURPOSES: We therefore asked: (1) Is the increased risk seen in overweight and obese patients, compared with patients in a normal BMI class, associated with increased operative time? (2) Is increased operative time independent of BMI class a risk factor for readmission, reoperation, and postoperative medical complications? (3) Does operative time modify the direction or strength of obesity-related adverse outcomes? METHODS: This retrospective, comparative study examined 247,108 patients who underwent THA between January 2014 and December 2020 in the National Surgical Quality Improvement Project (NSQIP). Of those, emergency cases (1% [2404]), bilateral procedures (1% [1605]), missing and/or null data (1% [3280]), extreme BMI and operative time outliers (1% [2032]), and patients with comorbidities that are not typical of an elective procedure, such as disseminated cancer, open wounds, sepsis, and ventilator dependence (1% [2726]), were excluded, leaving 95% (235,061) of elective, unilateral THA cases for analysis. The NSQIP was selected due to its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight, normal weight, overweight, Class I obesity, Class II obesity, and Class III obesity. Of the patients with a normal weight, 69% (30,932 of 44,556) were female and 36% (16,032 of 44,556) had at least one comorbidity, with a mean operative time of 86 ± 32 minutes and a mean age of 68 ± 12 years. Patients with obesity tend to be younger, male, more likely to have preoperative comorbidities, with longer operative times. Multivariable logistic regression models examined the effects of obesity on 30-day readmission, reoperation, and medical complications, while adjusting for age, sex, race, smoking status, and number of preoperative comorbidities. After we repeated this analysis after adjusting for operative time, an interaction model was conducted to test whether operative time changes the direction or strength of the association of BMI class and adverse outcomes. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were calculated, and the interaction effects were plotted. RESULTS: A comparison of patients with Class III obesity to patients with normal weight showed that the odds of readmission went from 45% (AOR 1.45 [95% CI 1.32 to 1.59]; p < 0.001) to 27% after adjusting for operative time (AOR 1.27 [95% CI 1.01 to 1.62]; p = 0.04), the odds of reoperation went from 93% (AOR 1.93 [95% CI 1.72 to 2.17]; p < 0.001) to 81% after adjusting for operative time (AOR 1.81 [95% CI 1.61 to 2.04]; p < 0.001), and the odds of a postoperative complication went from 96% (AOR 1.96 [95% CI 1.58 to 2.43]; p < 0.001) to 84% after adjusting for operative time (AOR 1.84 [95% CI 1.48 to 2.28]; p < 0.001). Each 15-minute increase in operative time was associated with a 7% increase in the odds of a readmission (AOR 1.07 [95% CI 1.06 to 1.08]; p < 0.001), a 10% increase in the odds of a reoperation (AOR 1.10 [95% CI 1.09 to 1.12]; p < 0.001), and 10% increase in the odds of a postoperative complication (AOR 1.10 [95% CI 1.08 to 1.13]; p < 0.001). There was a positive interaction effect of operative time and BMI for readmission and reoperation, which suggests that longer operations accentuate the risk that patients with obesity have for readmission and reoperation. CONCLUSION: Operative time is likely a proxy for surgical complexity and contributes modestly to the adverse outcomes previously attributed to obesity alone. Hence, focusing on modulating the accentuated risk associated with lengthened operative times rather than obesity is imperative to increasing the accessibility and safety of THA. Surgeons may do this with specific surgical techniques, training, and practice. Future studies looking at THA outcomes related to obesity should consider the association with operative time to focus on independent associations with obesity to facilitate more equitable access. LEVEL OF EVIDENCE: Level III, therapeutic study.

Identifying Risk Factors for Complication and Readmission with Same-Day Discharge Arthroplasty.

BACKGROUND: The COVID-19 pandemic caused a surge of same-day discharge (SDD) for total joint arthroplasty. However, SDD may not be beneficial for all patients. Therefore, continued investigation into the safety of SDD is necessary as well as risk stratification for improved patient outcomes. METHODS: This retrospective cohort study examined 31,851 elective SDD hip and knee arthroplasties from 2016 to 2020 in a large national database. Logistic regression models were used to identify patient variables and preoperative comorbidities that contribute to postoperative complication or readmission with SDD. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated. RESULTS: SDD increased from 1.4% in 2016 to 14.6% in 2020. SDD is associated with lower odds of readmission (AOR: 0.994, CI: 0.992-0.996) and postoperative complications (AOR: 0.998, CI: 0.997-1.000). Patients who have preoperative dyspnea (AOR: 1.03, CI: 1.02-1.04, P < .001), chronic obstructive pulmonary disease (AOR: 1.02, CI: 1.01-1.03, P = .002), and hypoalbuminemia (AOR: 1.02, CI: 1.00-1.03, P < .001), had higher odds of postoperative complications. Patients who had preoperative dyspnea (AOR: 1.02, CI: 1.01-1.03), hypertension (AOR: 1.01, CI: 1.01-1.03, P = .003), chronic corticosteroid use (AOR: 1.02, CI: 1.01-1.03, P < .001), bleeding disorder (AOR: 1.02; CI: 1.01-1.03, P < .001), and hypoalbuminemia (AOR: 1.01, CI: 1.00-1.02, P = .038), had higher odds of readmission. CONCLUSION: SDD is safe with certain comorbidities. Preoperative screening for cardiopulmonary comorbidities (eg, dyspnea, hypertension, and chronic obstructive pulmonary disease), chronic corticosteroid use, bleeding disorder, and hypoalbuminemia may improve SDD outcomes.

Single, Recurrent, Synchronous, and Metachronous Periprosthetic Joint Infections in Patients With Multiple Hip and Knee Arthroplasties.

BACKGROUND: The rate for periprosthetic joint infection (PJI) exceeds 1% for primary arthroplasties. Over 30% of patients who have a primary arthroplasty require an additional arthroplasty, and the impact of PJI on this population is understudied. Our objective was to assess the prevalence of recurrent, synchronous, and metachronous PJI in patients who had multiple arthroplasties and to identify risk factors for a subsequent PJI. METHODS: We identified 337 patients who had multiple arthroplasties and at least 1 PJI that presented between 2003 and 2021. The mean follow-up after revision arthroplasty was 3 years (range, 0 to 17.2). Patients who had multiple infected prostheses were categorized as synchronous (ie, presenting at the same time as the initial infection) or metachronous (ie, presenting at a different time as the initial infection). The PJI diagnosis was made using the MusculoSkeletal Infection Society (MSIS) criteria. RESULTS: There were 39 (12%) patients who experienced recurrent PJI in the same joint, while 31 (9%) patients developed PJI in another joint. Positive blood cultures were more likely in the second joint PJI (48%) compared to recurrent PJI (23%) or a single PJI (15%, P < .001). Synchronous PJI represented 42% of the second joint PJI cases (n = 13), while metachronous PJI represented 58% (n = 18). Tobacco users had 75% higher odds of metachronous PJI (odds ratio 1.75, 95% confidence interval: 1.1-2.9, P = .041). CONCLUSION: Over 20% of the patients with multiple arthroplasties and a single PJI will develop a subsequent PJI in another arthroplasty with 12% recurring in the initial arthroplasty and nearly 10% ocurring in another arthroplasty. Particular caution should be taken in patients who use tobacco, have bacteremia, or have Staphylococcus aureus isolation at time of their initial PJI. Optimizing the management of this high-risk patient population is necessary to reduce the additional burden of subsequent PJI. LEVEL OF EVIDENCE: Prognostic Level IV.

An External Acetabular Alignment Guide Decreases Positional Variance.

INTRODUCTION: Certain patient and operative factors limit accurate estimation of acetabular component positioning during total hip arthroplasty (THA). This study aimed to determine whether an intraoperative external alignment guide decreases variance in acetabular component positioning. MATERIALS AND METHODS: Adult patients who underwent primary THA from 2014-2018 were reviewed. Exclusion criteria were navigation, robot-assisted surgery, and inflammatory, post-traumatic, or avascular arthritis. One surgeon used an external guide while the second surgeon resected osteophytes and utilized available anatomical landmarks for positioning. Anteversion and inclination, variance, "safe zone" positioning, operative time, and hip instability were assessed. Multivariable regression models were used to examine effects on primary and secondary outcomes. RESULTS: 409 patients were included, of which 182 underwent component placement with landmarks only. Patients undergoing component placement with landmarks only were younger (p=0.002) and more often smokers (p=0.016). After multivariable risk adjustment, use of the external alignment guide was independently associated with 2.7° higher anteversion (CI: 1.6° to 3.8°) and smaller anteversion variance (-0.3, CI: -0.6 to 0.1) compared to landmarks only. It was independently associated with 3.2° higher inclination (CI: 2.0° to 4.4°), but there was no difference in inclination variance (-0.1, CI: -0.3 to 0.2). The external alignment guide was independently associated with a 14-minute shorter operative time (CI: 9.6 to 18.7) and smaller operative time variance (-0.9, CI: -1.2 to 0.6). DISCUSSION: Use of anatomical landmarks alone was associated with increased likelihood of safe zone positioning but lower precision and longer operative time. While this study was limited by lack of randomization and its retrospective nature, an acetabular positioner may be preferable to palpable or visible anatomy alone for acetabular component placement.

Do Proposed Quality Measures for Carpal Tunnel Release Reveal Important Quality Gaps and Are They Reliable?

BACKGROUND: The American Academy of Orthopaedic Surgeons recently proposed quality measures for the initial surgical treatment of carpal tunnel syndrome (CTS). One measure addressed avoidance of adjunctive surgical procedures during carpal tunnel release; and a second measure addressed avoidance of routine use of clinic-based occupational and/or physical therapy (OT/PT) after carpal tunnel release. However, for quality measures to serve their intended purposes, they must be tested in real-world data to establish that gaps in quality exist and that the measures yield reliable performance information. QUESTIONS/PURPOSES: (1) Is there an important quality gap in clinical practice for avoidance of adjunctive surgical procedures during carpal tunnel release? (2) Is there an important quality gap in avoiding routine use of clinic-based occupational and/or physical therapy after carpal tunnel release? (3) Do these two quality measures have adequate beta-binomial signal-to-noise ratio (SNR) and split-sample reliability (SSR)? METHODS: This retrospective comparative study used a large national private insurance claims database, the 2018 Optum Clinformatics® Data Mart. Ideally, healthcare quality measures are tested within data reflective of the providers and payors to which the measures will be applied. We previously tested these measures in a large public healthcare system and a single academic medical center. In this study, we sought to test the measures in the broader context of patients and providers using private insurance. For both measures, we included the first carpal tunnel release from 28,083 patients performed by one of 7236 surgeons, irrespective of surgical specialty (including, orthopaedic, plastic, neuro-, and general surgery). To calculate surgeon-level descriptive and reliability statistics, analyses were focused on the 66% (18,622 of 28,083) of patients who received their procedure from one of the 24% (1740 of 7236) of surgeons with at least five carpal tunnel releases in the database. No other inclusion/exclusion criteria were applied. To determine whether the measures reveal important gaps in treatment quality (avoidance of adjunctive procedures and routine therapy), we calculated descriptive statistics (median and interquartile range) of the performance distribution stratified by surgeon-level annual volume of carpal tunnel releases in the database (5+, 10+, 15+, 20+, 25+, and 30+). Like the Centers for Medicare & Medicaid Services (CMS), we considered a measure "topped out" if median performance was greater than 95%, meaning the opportunity for further quality improvement is low. We calculated the surgeon-level beta-binomial SNR and SSR for each measure, each stratified by the number of carpal tunnel releases performed by each surgeon in the database. These are standard measures of reliability in health care quality measurement science. The SNR quantifies the proportion of variance that is between rather than within surgeons, and the SSR is the correlation of performance scores when each surgeons' patients are split into two random samples and then corrected for sample size. RESULTS: We found that 2% (308 of 18,622) of carpal tunnel releases involved an adjunctive procedure. The results showed that avoidance of adjunctive surgical procedures during carpal tunnel release had a median (IQR) performance of 100% (100% to 100%) at all case volumes. Only 8% (144 of 1740) of surgeons with at least five cases in the database had less than 100% performance, and only 5% (84 of 1740) had less than 90% performance. This means adjunctive procedures were rarely performed and an important quality gap does not exist based on the CMS criterion. Regarding the avoidance of routine therapy, there was a larger quality gap: For surgeons with at least five cases in the database, median performance was 89% (75% to 100%), and 25% (435 of 1740) of these surgeons had less than 75% performance. This signifies that the measure is not topped out and may reveal an important quality gap. Most patients receiving clinic-based OT/PT had only one visit in the 6 weeks after surgery. Median (IQR) SNRs of the first measure, which addressed avoidance of adjunctive surgical procedures, and the second measure, which addresses avoidance of routine use clinic-based OT/PT, were 1.00 (1.00 to 1.00) and 0.86 (0.67 to 1.00), respectively. The SSR for these measures were 0.87 (95% CI 0.85 to 0.88) and 0.75 (95% CI 0.73 to 0.77), respectively. All of these reliability statistics exceed National Quality Forum's emerging minimum standard of 0.60. CONCLUSION: The first measure, the avoidance of adjunctive surgical procedures during carpal tunnel release, lacked an important quality gap suggesting it is unlikely to be useful in driving improvements. The second measure, avoidance of routine use of clinic-based OT/PT, revealed a larger quality gap and had very good reliability, suggesting it may be useful for quality monitoring and improvement purposes. CLINICAL RELEVANCE: As healthcare systems and payors use the second measure, avoidance of routine use of clinic-based OT/PT, to encourage adherence to clinical practice guidelines (such as provider profiling, public reporting, and payment policies), it will be critically important to consider what proportion of patients receiving OT/PT should be considered routine practice and therefore inconsistent with guidelines. The value or potential harm of this measure depends on this judgement.

A national survey of barriers and facilitators to medications for opioid use disorder among legal-involved veterans in the Veterans Health Administration.

Background: Medications for opioid use disorder (MOUD) are clinically effective at treating OUD among legal-involved populations. However, research shows that legal-involved veterans who receive care through the VHA have lower rates of MOUD use compared to non-legal-involved veterans. Education may be a key factor in intervention strategies to improve MOUD access. This study was a national survey of VHA staff to identify barriers to and facilitators of MOUD, as well as MOUD-related education needs for VHA staff, community partners, criminal justice partners, and legal-involved veterans. Method: A 98-item online survey was conducted to examine VHA staff perspectives (N = 218) around needed education, barriers to, and facilitators of MOUD for legal-involved veterans. Descriptive statistics were conducted and linear regression analyses were used to evaluate differences in perceptions by respondents' current position at the VHA and their VHA facility's rate of provision of MOUD among legal-involved veterans. Results: Respondents endorsed a need for education in all areas of MOUD (e.g., existing medications for the treatment of OUD) for VHA staff and providers, community partners, criminal justice partners, and legal-involved veterans. VHA staff perceived barriers to MOUD for legal-involved veterans to include stigma and complicated guidelines around MOUD and OUD treatment. Facilities with low rates of MOUD use highlighted barriers including MOUD conflicting with the philosophy of the local VHA facility and provider stigma toward patients with OUD. Perceptions of efficacy of MOUD differed by respondents' current position at the VHA such that substance use disorder treatment providers perceived buprenorphine and methadone as more effective compared to Veterans Justice Specialists. Conclusion: The results of this study suggest a need for an educational intervention emphasizing the evidence supporting use of MOUD as a lack of knowledge about these medications was considered a barrier to access, whereas gaining education about MOUD was a facilitator to access. Education strategies specifically tailored to address VHA facility-level differences may help address barriers to MOUD experienced by legal-involved veterans.

Delta Studies: Expanding the Concept of Deviance Studies to Design More Effective Improvement Interventions.

BACKGROUND: The effects of improvement (implementation and de-implementation) interventions are often modest. Although positive and negative deviance studies have been extensively used in improvement science and quality improvement efforts, conceptual and methodological innovations are needed to improve our ability to use information about variation in quality to design more effective interventions. OBJECTIVE: We describe a novel mixed methods extension of the deviance study we term "delta studies." Delta studies seek to quantitatively identify sites that have recently changed from low performers to high performers, or vice versa, in order to qualitatively learn about active strategies that produced recent change, challenges change agents faced and how they overcame them, and where applicable, the causes of recent deterioration in performance-information intended to inform the design of improvement interventions for deployment in low performing sites. We provide examples of lessons learned from this method that may have been missed with traditional positive or negative deviance designs. DESIGN: Considerations for quantitatively identifying delta sites are described including which quality metrics to track, over what timeframe to observe change, how to account for reliability of observed change, consideration of patient volume and initial performance as implementation context factors, and how to define clinically meaningful change. Methods to adapt qualitative protocols by integrating quantitative information about change in performance are also presented. We provide sample data and R code that can be used to graphically display distributions of initial status, change, and volume that are essential to delta studies. PARTICIPANTS: Patients and facilities of the US Veterans Health Administration. KEY RESULTS: As an example, we discuss what decisions we made regarding the delta study design considerations in a funded study of low-value preoperative testing. The method helped us find sites that had recently reduced the burden of low-value testing, and learn about the strategies they employed and challenges they faced. CONCLUSIONS: The delta study concept is a promising mixed methods innovation to efficiently and effectively identify improvement strategies and other factors that have actually produced change in real-world settings.

Effects of unloader bracing on clinical outcomes and articular cartilage regeneration following microfracture of isolated chondral defects: a randomized trial.

PURPOSE: To determine whether the use of an unloading brace can increase the thickness of cartilage regenerate after microfracture surgery. METHODS: This is a randomized (1:1) controlled clinical trial. Twenty-four patients who underwent microfracture between 2012 and 2015 were identified and were randomly assigned to an unloading brace group or a no-brace group. All patients were kept non-weight bearing for the first eight weeks after surgery and then patients in the intervention group began using an unloading brace for an average of 63.9 (SD = 41.6) days to protect clot stability by exerting a varus or valgus force on the knee to decrease the force on the knee's lateral or medial compartment, respectively. Quality of the cartilage repair was assessed with knee magnetic resonance imaging to determine repair tissue thickness (primary outcome), repair tissue volume, and T2 relaxation times at 12 and 24 months after surgery. Clinical outcomes were evaluated with KOOS, Tegner, SF12, and Lysholm questionnaires at six, 12 and 24 months after surgery. RESULTS: Three patients were lost to follow-up, resulting in 21 patients ultimately analyzed. The unloading brace repair tissue was greater than the no-brace group in volume (26.8 ± 23.7 mm3 vs - 8.4 ± 22.7 mm3, p = 0.005) and thickness (0.2 ± 0.2 mm versus - 0.4 ± 0.3 mm, p = 0.001) at 12 months and in cartilage thickness in the unloading brace group at 24 months (0.4 ± 0.4 mm versus - 0.1 ± 0.3 mm, p = 0.029). There was a positive correlation between wearing the brace longer and improved 6-month KOOS symptom scores (r = 0.82, p = 0.013), 6-month KOOS QOL scores (r = 0.80, p = 0.017), 6-month Tegner scores (r = 0.94, p = 0.002), and Tegner score changes from baseline to 6 months (r = 0.80, p = 0.032). CONCLUSION: This study found a significant mid-term increase in cartilage repair tissue thickness following unloading bracing in patients recovering from microfracture for isolated chondral defects. LEVEL OF EVIDENCE: II.

Perioperative Statin Use May Reduce Postoperative Arrhythmia Rates After Total Joint Arthroplasty.

BACKGROUND: Postoperative arrhythmias are associated with increased morbidity and mortality in total joint arthroplasty (TJA) patients. HMG-CoA (3-hydroxy-3-methyl-glutaryl-CoA) reductase inhibitors (statins) decrease atrial fibrillation rates after cardiac surgery, but it is unknown if this cardioprotective effect is maintained after joint reconstruction surgery. We aim to determine if perioperative statin use decreases the incidence of 90-day postoperative arrhythmias in patients undergoing primary TJA. METHODS: We performed a single-center retrospective cohort study in which 231 primary TJA patients (109 hips, 122 knees) received simvastatin 80 mg daily during their hospitalization as part of a single surgeon's standard postoperative protocol. This cohort was matched to 966 primary TJA patients (387 hips and 579 knees) that did not receive simvastatin. New-onset arrhythmias (bradycardia, atrial fibrillation/tachycardia/flutter, paroxysmal supraventricular tachycardia, and ventricular tachycardia) and complications (readmissions, thromboembolism, infection, and dislocation) within 90 days of the procedure were documented. Categorical variables were analyzed using Fisher's exact tests. Our study was powered to detect a 3% difference in arrhythmia rates. RESULTS: Within 90 days postoperatively, arrhythmias occurred in 1 patient (0.4%) who received a perioperative statin, 39 patients (4.0%) who did not receive statins (P = .003), and 24 patients (4.2%) who were on outpatient statins (P = .005). This is 10-fold reduction in the relative risk of developing a postoperative arrhythmia within 90 days of arthroplasty and an absolute risk reduction of 3.6%. CONCLUSION: Treating as few as 28 patients with perioperative simvastatin prevents one new cardiac arrhythmia within 90 days in statin-naïve patients undergoing TJA.

Barriers to Medications for Opioid Use Disorder Among Veterans Involved in the Legal System: a Qualitative Study.

BACKGROUND: Veterans involved in the legal system are at high risk for overdose but have lower receipt of medications for opioid use disorder than other veterans. OBJECTIVE: The study aimed to understand barriers to medication access from the perspective of legally involved veterans with opioid use disorder and people who work with these veterans in the Veterans Health Administration (VHA) and the legal system. DESIGN: This national qualitative study interviewed veterans and stakeholders from 14 geographically diverse VHA facilities to explore perceptions of barriers to medications for opioid use disorder. PARTICIPANTS: Participants included veterans with a history of opioid use disorder and legal involvement (n = 18), VHA Veterans Justice Programs Specialists (n = 15), VHA and community substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12). APPROACH: We conducted interviews based on the Consolidated Framework for Implementation Research. Interview transcripts were analyzed using a team-based approach. KEY RESULTS: Four key barriers, noted by group, were identified: (1) a preference for counseling along with or instead of medications (veterans, Specialists, treatment providers, criminal justice staff); (2) concerns about veterans using medications without a prescription, selling them, or providing them to others (veterans, Specialists, treatment providers, criminal justice staff); (3) concerns about perceived stigma towards medication use (veterans, Specialists, treatment providers, criminal justice staff); and (4) concerns about medication discontinuation after recurrent opioid use (veterans, criminal justice staff). A fifth theme, education, was noted by all stakeholders except providers as important to facilitating use of medications for opioid use disorder. All five themes mapped to the framework construct of knowledge and beliefs about the intervention. CONCLUSIONS: Based on identified barriers, interventions focused on enhancing medication knowledge, reducing stigma towards use of medications, and increasing knowledge that opioid use may recur during treatment may help increase access to medication for veterans with legal involvement.

Posttraumatic Stress Disorder and Justice Involvement Among Military Veterans: A Systematic Review and Meta-Analysis.

There is evidence of an association between posttraumatic stress disorder (PTSD) and criminal justice involvement among military veterans. For this study, we systematically reviewed the literature to examine the association between PTSD and criminal justice involvement among military veterans, assess the magnitude of this association, and identify strengths and limitations of the underlying evidence. Five databases were searched for a larger scoping review, and observational studies that assessed PTSD and criminal justice involvement were selected from the scoping review database (N = 191). Meta-analyses were conducted, pooling odds ratios (ORs) via restricted maximum likelihood random-effects models. The main outcomes were criminal justice involvement (i.e., documentation of arrest) and PTSD (i.e., PTSD assessment score indicating probable PTSD). Of 143 unique articles identified, 10 studies were eligible for the meta-analysis. Veterans with PTSD had higher odds of criminal justice involvement (OR = 1.61, 95% CI [1.16, 2.23], p = .002) and arrest for violent offenses (OR = 1.59, 95% CI [1.15, 2.19], p = .002) compared to veterans without PTSD. The odds ratio of criminal justice involvement among military veterans with PTSD assessed using the PTSD Checklist was 1.98, 95% CI [1.08, 3.63], p = .014. Considerable heterogeneity was identified, but no evidence of publication bias was found. Criminal justice involvement and PTSD are linked among military veterans, highlighting an important need for clinicians and healthcare systems working with this population to prioritize PTSD treatment to reduce veterans' new and recurring risk of criminal justice involvement.

Testing proposed quality measures for treatment of carpal tunnel syndrome: feasibility, magnitude of quality gaps, and reliability.

BACKGROUND: The American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand recently proposed three quality measures for carpal tunnel syndrome (CTS): Measure 1 - Discouraging routine use of Magnetic resonance imaging (MRI) for diagnosis of CTS; Measure 2 - Discouraging the use of adjunctive surgical procedures during carpal tunnel release (CTR); and Measure 3 - Discouraging the routine use of occupational and/or physical therapy after CTR. The goal of this study were to 1) Assess the feasibility of using the specifications to calculate the measures in real-world healthcare data and identify aspects of the specifications that might be clarified or improved; 2) Determine if the measures identify important variation in treatment quality that justifies expending resources for their further development and implementation; 3) Assess the facility- and surgeon-level reliability of measures. METHODS: The measures were calculated using national data from the Veterans Health Administration (VA) Corporate Data Warehouse for three fiscal years (FY; 2016-18). Facility- and surgeon-level performance and reliability were examined. To expand the testing context, the measures were also tested using data from an academic medical center. RESULTS: The denominator of Measure 1 was 132,049 VA patients newly diagnosed with CTS. The denominators of Measures 2 and 3 were 20,813 CTRs received by VA patients. The median facility-level performances on the three measures were 96.5, 100, and 94.7%, respectively. Of 130 VA facilities, none had < 90% performance on Measure 1. Among 111 facilities that performed CTRs, only 1 facility had < 90% performance on Measure 2. In contrast, 21 facilities (18.9%) and 333 surgeons (17.8%) had lower than 90% performance on Measure 3 (Median facility- and surgeon-level reliability for Measure 3 were very high (0.95 and 0.96 respectively). CONCLUSIONS: Measure 3 displayed adequate facility- and surgeon-level variability and reliability to justify its use for quality monitoring and improvement purposes. Measures 1 and 2 lacked quality gaps, suggesting they should not be implemented in VA and need to be tested in other healthcare settings. Opportunities exist to refine the specifications of Measure 3 to ensure that different organizations calculate the measure in the same way.

Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery.

BACKGROUND: The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA). METHODS: Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression. RESULTS: From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT. CONCLUSIONS: Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.