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BACKGROUND: The purpose of this study was to evaluate the effect of concomitant open distal clavicle excision (DCE) on postoperative clinical outcomes and incidence of acromial and scapular stress fractures (ASFs) in patients with symptomatic acromioclavicular joint osteoarthritis (ACJ OA) undergoing reverse total shoulder arthroplasty (RTSA). METHODS: A single-surgeon retrospective cohort study was conducted including patients who underwent primary elective RTSA with or without DCE from 2015 to 2019 with a minimum 6-month follow-up period. Shoulder active range of motion (AROM) and visual analog scale (VAS) pain were recorded preoperatively and postoperatively. ASFs and other adverse events were identified using postoperative notes and/or radiographs. Characteristics and outcomes were compared between the RTSA and RTSA-DCE groups. RESULTS: Forty-six RTSA patients (mean age, 67.9±8.7 years; 60.9% male; mean follow-up, 24.9±16.6 months) and 70 RTSA-DCE patients (mean age, 70.2±8.9 years; 20.0% male; mean follow-up, 22.7±12.9 months) were included. There were no significant intergroup differences in rates of ASF (RTSA, 0.0% vs. RTSA-DCE, 1.4%; P=1.00), stress reactions (RTSA, 8.7% vs. RTSA-DCE, 11.4%; P=0.76), reoperation, revision, or infection (all P>0.05), or in pre-to-postoperative reduction in VAS pain (P=0.17) at latest follow-up. However, the RTSA-DCE group had greater pre-to-postoperative improvement in flexion AROM (RTSA, 43.7°±38.5° vs. RTSA-DCE, 59.5°±33.4°; P=0.03) and internal rotation (IR) AROM (P=0.02) at latest follow-up. CONCLUSIONS: Concomitant DCE in RTSA improves shoulder flexion and IR AROM, alleviates shoulder pain, and does not increase the risk of ASFs. Level of evidence: III.
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Background: Tophaceous gout affecting the olecranon region can result in local discomfort, skin ulceration, secondary infection, and considerable disability if left untreated. However, there are limited reports of outcomes, including postoperative complications and recurrence after surgical excision of tophaceous gout deposits at the elbow. The aim of this study is to present our surgical technique and minimum one-year outcomes after surgical excision of tophaceous gout involving the elbow. Methods: A retrospective chart review was performed on all patients from a single surgeon's practice who underwent surgical excision of gouty tophi of the elbow between January 2016 and December 2019. The indications for surgical excision of tophi included failure of medical management, presence of skin ulceration, and/or large gouty tophi. The relevant data pertaining to patient demographics, preoperative findings, intraoperative findings, surgical pathology reports, and short-term postoperative complications were collected through retrospective chart review. Patients were subsequently contacted for a follow-up telehealth visit to assess recurrence of gouty tophi, functional outcomes, and range of motion (ROM) measurements. Results: Six male patients underwent 7 total procedures (1 bilateral elbow) during the study period. The mean age of the cohort at the time of surgery was 56.0 ± 7.1 years (range: 45.3-63.5). The mean size of the swelling in 2 maximum dimensions was 5.8 × 3.4 cm. There were no intraoperative or immediate postoperative wound complications. There was no recurrence of gouty tophi at a mean follow-up time of 30.8 months (range: 14.0-43.5). Patients reported physiologic ROM (mean flexion-extension arc of 2°-134°) with no pain at final follow-up. Conclusion: Surgical treatment of tophaceous gout of the elbow is associated with a low risk of wound complication and recurrence.
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The Latarjet-Patte procedure has a long and storied history that predates shoulder arthroscopy, but its popularity has increased over the past two decades as a treatment for anterior glenohumeral instability with bone loss. Transfer of the coracoid process and conjoint tendon to the anteroinferior glenoid creates a triple-blocking effect that is both static and dynamic, lending it biomechanical superiority over alternative bone block techniques. Patients undergoing the Latarjet-Patte procedure have low rates of recurrent instability compared to arthroscopic soft-tissue stabilization procedures, particularly in the setting of glenoid- and humeral-sided bone loss. A number of technical innovations have been developed in recent years to improve the efficacy of this procedure and to reduce its potential complications, although their associated learning curves and potential for widespread adoption remain unclear. In this article, we review the history, indications, outcomes, and future of this surgical technique.
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Inestabilidad de la Articulación , Luxación del Hombro , Articulación del Hombro , Artroscopía/efectos adversos , Artroscopía/métodos , Humanos , Inestabilidad de la Articulación/etiología , Inestabilidad de la Articulación/cirugía , Escápula/cirugía , Luxación del Hombro/cirugía , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugíaRESUMEN
PURPOSE: To report on our institution's first year of experience with a preferred vendor program for implants and disposables for sports medicine surgery. METHODS: Cost and utilization data for implants and disposables were analyzed for knee and shoulder sports medicine surgeries performed during the 2-year period including the 12 months preceding the start of the contract (contract year 0 [CY0] and the first 12 months of the contract period (CY1). The costs of grafts and biological therapies were excluded. Utilization of the preferred vendor's products, operative time, and per-case costs were compared between the 2 time periods and adjusted for patient factors and case mix. RESULTS: Utilization of the preferred vendor's shavers (0% to 94%, P < .001) and radiofrequency ablation wands (0% to 91%, P < .001) increased significantly in CY1 (n = 5,068 cases) compared with CY0 (n = 5,409 cases), with a small but significant increase in use of the preferred vendor's implants (64% to 67%, P = .023). There was no significant difference in mean operative time between CY0 and CY1 (P = .485). Mean total per-case implant and disposable costs decreased by 12% (P < .001) in CY1 versus CY0. CONCLUSION: Our institution was able to reduce the costs of sports medicine surgery with the implementation of a preferred single-vendor program for implants and disposables. This program had widespread surgeon adoption and did not have any detrimental effect on operating room efficiency. LEVEL OF EVIDENCE: III, retrospective comparative study.
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Modelos Teóricos , Medicina Deportiva , Procedimientos Quirúrgicos Operativos , Estudios de Cohortes , Comercio , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Estudios Retrospectivos , Medicina Deportiva/economía , Cirujanos , Procedimientos Quirúrgicos Operativos/economíaRESUMEN
BACKGROUND: Workers Compensation claims have been previously associated with inferior clinical outcomes. However, variation in inpatient stays for orthopedic trauma injuries according to insurance type has not been previously examined. METHODS: We investigated the differences according to insurance for tibial shaft fractures in regard to length of stay and disposition. Using the New York SPARCS database, we identified 1,856 adult non-elderly patients with an isolated tibial shaft fracture who underwent surgery. Patients were stratified by insurance type, including private, Medicaid, Workers Compensation, and no-fault, which covers medical expenses related to automobile or pedestrian accidents. RESULTS: Compared to private insurance (mean: 2.7 days), length of stay was longer for no-fault (mean: 3.9 days; adjusted difference +33%, p < 0.001) and Medicaid (mean: 3.5 days; adjusted difference +22%, p < 0.001), but not significantly different for Workers Compensation (mean: 3.5 days; adjusted difference +4%, p = 0.474). Compared to private insurance (rate: 3.5%), disposition to a facility was significantly higher for no-fault (rate: 10.1%; adjusted odds ratio [OR] = 3.3, p < 0.001) and Medicaid (rate: 7.6%; OR = 2.2, p = 0.003), but was not significantly different for Workers Compensation (rate: 6.3%; OR = 1.8, p = 0.129). CONCLUSIONS: Patients with no-fault insurance, but not Workers Compensation, are subject to longer hospital stays and are more likely to be discharged to a facility following operative fixation of an isolated tibial shaft fracture. These findings suggest that financial, social, and legal factors influence medical care for patients involved in automobile accidents with no-fault insurance.
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Accidentes de Tránsito/economía , Fijación de Fractura , Seguro de Responsabilidad Civil/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Fracturas de la Tibia , Indemnización para Trabajadores/estadística & datos numéricos , Adulto , Femenino , Fijación de Fractura/economía , Fijación de Fractura/rehabilitación , Fijación de Fractura/estadística & datos numéricos , Humanos , Revisión de Utilización de Seguros/estadística & datos numéricos , Masculino , Evaluación de Resultado en la Atención de Salud , Fracturas de la Tibia/economía , Fracturas de la Tibia/etiología , Fracturas de la Tibia/cirugía , Estados UnidosRESUMEN
BACKGROUND: In total joint arthroplasty, variation in implant use can be driven by vendor relationships, surgeon preference, and technological advancements. Our institution developed a preferred single-vendor program for primary hip and knee arthroplasty. We hypothesized that this initiative would decrease implant costs without compromising performance on quality metrics. METHODS: The utilization of implants from the preferred vendor was evaluated for the first 12 months of the contract (September 1, 2017, to August 31, 2018; n = 4,246 cases) compared with the prior year (September 1, 2016, to August 31, 2017; n = 3,586 cases). Per-case implant costs were compared using means and independent-samples t tests. Performance on quality metrics, including 30-day readmission, 30-day surgical site infection (SSI), and length of stay (LOS), was compared using multivariable-adjusted regression models. RESULTS: The utilization of implants from the preferred vendor increased from 50% to 69% (p < 0.001), with greater use of knee implants than hip implants from the preferred vendor, although significant growth was seen for both (from 62% to 81% for knee, p < 0.001; and from 38% to 58% for hip, p < 0.001). Adoption of the preferred-vendor initiative was greatest among low-volume surgeons (from 22% to 87%; p < 0.001) and lowest among very high-volume surgeons (from 61% to 62%; p = 0.573). For cases in which implants from the preferred vendor were utilized, the mean cost per case decreased by 23% in the program's first year (p < 0.001), with an associated 11% decrease in the standard deviation. Among all cases, there were no significant changes with respect to 30-day readmission (p = 0.449) or SSI (p = 0.059), while mean LOS decreased in the program's first year (p < 0.001). CONCLUSIONS: The creation of a preferred single-vendor model for hip and knee arthroplasty implants led to significant cost savings and decreased cost variability within the program's first year. Higher-volume surgeons were less likely to modify their implant choice than were lower-volume surgeons. Despite the potential learning curve associated with changes in surgical implants, there was no difference in short-term quality metrics. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Ahorro de Costo , Prótesis de Cadera/economía , Prótesis de la Rodilla/economía , Comercialización de los Servicios de Salud/organización & administración , Adaptación Psicológica , Artroplastia de Reemplazo de Cadera/economía , Artroplastia de Reemplazo de Cadera/métodos , Artroplastia de Reemplazo de Rodilla/economía , Artroplastia de Reemplazo de Rodilla/métodos , Estudios de Cohortes , Femenino , Prótesis de Cadera/estadística & datos numéricos , Humanos , Prótesis de la Rodilla/estadística & datos numéricos , Masculino , Evaluación de Programas y Proyectos de Salud , Análisis de Regresión , Estudios Retrospectivos , Cirujanos/psicologíaRESUMEN
INTRODUCTION: Magnet Recognition is the highest distinction a healthcare organization can receive for excellence in nursing. Although Magnet status is generally associated with superior clinical outcomes and patient satisfaction, its association with performance on nationwide quality metrics is currently unknown. METHODS: Within a propensity score-matched cohort, we compared performance on the Hospital-Acquired Condition Reduction Program (HACRP), Hospital Value-Based Purchasing (VBP), and Hospital Readmissions Reduction Program (RRP) initiatives. RESULTS: The mean HACRP total performance score was inferior at Magnet versus non-Magnet hospitals (p < .001), and HACRP penalties were more likely to be levied against Magnet hospitals (p = .003). There was no significant difference according to Magnet status for VBP penalties after correcting for multiple comparisons (p = .049). There were no significant difference in RRP penalties according to Magnet status (p = .999). CONCLUSIONS: Magnet hospitals performed worse on a number of hospitalwide quality metrics tied to reimbursement by the Centers for Medicare and Medicaid Service. Although Magnet hospitals are known for superior nursing care and organizational support for safety and quality improvement, this is not captured within these composite measures of quality, which can be influenced at many levels of care. These data underscore the need for comprehensive quality improvement across multiple domains of care outside of nursing. LEVEL OF EVIDENCE: Level III, retrospective study.
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Enfermedad Iatrogénica/prevención & control , Medicaid/normas , Medicare/normas , Atención de Enfermería/normas , Readmisión del Paciente/normas , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Benchmarking , Humanos , Medicaid/estadística & datos numéricos , Medicare/estadística & datos numéricos , Atención de Enfermería/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Mejoramiento de la Calidad/estadística & datos numéricos , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Estudios Retrospectivos , Estados UnidosRESUMEN
BACKGROUND: For patients undergoing total elbow arthroplasty (TEA), the present study aimed to investigate: (i) what risk factors are associated with periprosthetic elbow infection; (ii) what is the incidence of infection after TEA; and (iii) what is the acuity with which these infections present? METHODS: The Statewide Planning and Research Cooperative System database was used to identify all patients who underwent TEA between 2003 and 2012 in New York State. Admissions for prosthetic joint infection (PJI) were identified using ICD-9 (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code 996.66. Multivariate analysis was used to determine risk factors that were independently prognostic for PJI. RESULTS: Significant risk factors for PJI included hypothyroidism [odds ratio (OR) = 2.04; p = 0.045], tobacco use disorder (OR = 3.39; p = 0.003) and rheumatoid arthritis (OR = 3.31; p < 0.001). Among the 1452 patients in the study period who underwent TEA, 3.7% (n = 54) were admitted postoperatively for PJI. There were 30 (56%) early infections, 17 (31%) delayed infections and seven (13%) late infections. CONCLUSIONS: Pre-operative optimization of thyroid function, smoking cessation and management of rheumatoid disease may be considered in surgical candidates for TEA. The results of the present study add prognostic data to the literature that may be helpful with patient selection and risk profile analysis. LEVEL OF EVIDENCE: Level III: prognostic study.
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BACKGROUND: Smoking is associated with adverse outcomes after total joint arthroplasty (TJA), including periprosthetic joint infection (PJI). Although preoperative smoking cessation interventions may help reduce the risk PJI, the short-term cost-effectiveness of these programs remains unclear. METHODS: Decision analysis was used to evaluate the cost-effectiveness of a preoperative smoking cessation intervention over a 90-day TJA episode of care. Costs and probabilities were derived from literature review and published Medicare data. Thresholds for cost and efficacy of the intervention were determined using sensitivity analysis. RESULTS: In our model, the average 90-day cost was $32 less for patients enrolled in a mandatory smoking cessation intervention ($23,457) compared with patients who were not ($23,489). In sensitivity analyses, the smoking cessation intervention was cost-saving vs no intervention when the short-term cost of PJI was greater than $95,410, the rate of PJI was reduced by at least 25% for former vs current smokers, the cost of the intervention was less than $219, or the success rate of the intervention was greater than 56%. CONCLUSION: Smoking cessation interventions prior to TJA can increase the value of care and are an important public health initiative. Routine referral to smoking cessation interventions should be considered for smokers indicated for TJA. LEVEL OF EVIDENCE: Level II, economic and decision analyses.
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Artroplastia de Reemplazo/economía , Cuidados Intraoperatorios/economía , Cese del Hábito de Fumar/economía , Artroplastia , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Humanos , FumarRESUMEN
STUDY DESIGN/SETTING: This was a retrospective cohort study. PURPOSE: The purpose of this study was to examine the association between postoperative cerebrospinal fluid (CSF) leak and anterior cervical discectomy and fusion (ACDF). Specifically, we evaluated: (1) demographic risk factors; (2) comorbid risk factors; (3) indications for surgery; and (4) lengths of stay. SUMMARY OF BACKGROUND DATA: CSF leak is a rare but serious complication of ACDF. Currently, there is a paucity of literature describing the risk factors for CSF leak following ACDF. METHODS: The Nationwide Inpatient Sample was used to identify all patients who underwent cervical fusion using the anterior approach with excision of intervertebral disc between 1998 and 2010. Patients who had a diagnosis of ossification of the posterior longitudinal ligament in the cervical region were excluded. All patients who had a CSF leak were identified. Demographics and comorbidities were compared via χ analysis, and logistic regression to calculate the odds of having a CSF leak. RESULTS: Of the 1,261,140 patients identified, 3048 patients (0.24%) had a postoperative CSF leak. Patients who were between the ages of 55 and 69 years (P=0.038) and 70 years or older (P=0.001) were at an increased risk of CSF leak compared with patients who were aged 40-54 years. Non-white race (P=0.021), obesity, (P<0.001) and hypertension (P=0.025) were associated with an increased risk of CSF leak, but diabetes (P=0.966) and hyperlipidemia (P=0.226) were not. Herniated disc diagnosis was associated with decreased risk of CSF leak (P=0.032), but cervical spondylosis with myelopathy patients had an increased risk (P<0.001). Patients with CSF leak had a mean length of stay of 6.0 days compared with 2.1 days among controls. CONCLUSIONS: Surgical candidates who are older and non-white should be counseled of their increased risk for CSF leak in preoperative planning. Patients who are obese and have hypertension may benefit from medical optimization before surgery. LEVEL OF EVIDENCE: Level III.
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Pérdida de Líquido Cefalorraquídeo/etiología , Vértebras Cervicales/cirugía , Discectomía/efectos adversos , Fusión Vertebral/efectos adversos , Adolescente , Adulto , Anciano , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Factores de Riesgo , Adulto JovenRESUMEN
Accelerated discharge protocols for scoliosis surgery have recently been described in the literature. There are limited data describing the association of length of stay (LOS) during the index admission with postoperative outcomes. We sought to define the economic and clinical implications of an additional 1 day in the hospital for scoliosis surgery. The Statewide Planning and Research Cooperative System database was used to identify patients with adolescent idiopathic scoliosis who underwent spinal fusion from 1 October 2007 to 30 September 2012 at high-volume institutions (>20 cases/year) in the state of New York. Regression models were adjusted for age, sex, race, insurance, comorbidity score, and perioperative complications during the index admission. Among the 1286 patients with AIS who underwent spinal fusion, the mean LOS was 4.90 days [95% confidence interval (CI)=4.84-4.97; SD=1.19]. In the perioperative period, 605 (47.05%) underwent transfusion and 202 (15.71%) had problems with pain control. An additional 1 day in the hospital was associated with $11 033 (95% CI=7162-14 904; P<0.001) in insurance charges, $5198 (95% CI=4144-6252; P<0.001) in hospital costs, 28% increased risk (odds ratio=1.28; 95% CI=1.01-1.63; P=0.041) of all-cause 90-day readmission, and a 57% increased risk (odds ratio=1.57; 95% CI=1.13-2.17; P=0.007) of returning to the operating room within 90 days. Increased LOS during the index admission scoliosis surgery is associated with higher costs and an increased risk of 90-day postoperative complications. Protocols to decrease LOS for this surgery have potential benefits to patients, hospitals, and insurers. Level of Evidence: Level III, retrospective comparative study.
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Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Escoliosis/cirugía , Adolescente , Transfusión Sanguínea/estadística & datos numéricos , Niño , Femenino , Precios de Hospital/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Humanos , Masculino , New York/epidemiología , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Riesgo , Fusión Vertebral , Adulto JovenRESUMEN
INTRODUCTION: The transition to bundled payment reimbursement for geriatric hip fractures has incentivized the identification of avoidable inefficiencies in the cost and quality of care. Although a "weekend effect" has been described with regard to hip fracture mortality, measures of efficiency according to the day of hip fracture admission are currently unclear. METHODS: We identified 62,303 patients aged 65 years or older with a primary diagnosis of femoral neck or intertrochanteric hip fracture in the New York Statewide Planning and Research Cooperative System between 2009 and 2014. Outcome measures included preoperative delay, postoperative length of stay (LOS), and cost of admission. RESULTS: Preoperative delay was longer for weekend admissions, but shorter for admissions on Wednesday, Thursday, and Friday. Postoperative LOS was longer for admissions on Tuesday, Wednesday, and Thursday. Discharge rates varied considerably according to the day of admission, ranging from 12% to 43% by hospital day 4 and 53% to 72% by hospital day 6. No differences in cost according to day of admission were found once preoperative delay and postoperative LOS were accounted for. DISCUSSION: Notable variation exists in hospitalizations for geriatric hip fracture depending on the day of admission. Our data suggest the presence of a weekend effect, in which changes in staffing of surgical, medical, and ancillary services lead to increased waiting times for surgery for new admissions and delays in discharge of early- and mid-week admissions. LEVEL OF EVIDENCE: Level III, retrospective study.
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Fracturas del Cuello Femoral/cirugía , Fracturas de Cadera/cirugía , Tiempo de Internación , Tiempo de Tratamiento , Anciano , Artroplastia de Reemplazo de Cadera , Eficiencia Organizacional , Fijación Interna de Fracturas , Administración Hospitalaria , Costos de Hospital , Hospitales/normas , Humanos , Tiempo de Internación/economía , New York , Evaluación de Resultado en la Atención de Salud , Mecanismo de Reembolso , Estudios Retrospectivos , Factores de Tiempo , Tiempo de Tratamiento/economía , Tiempo de Tratamiento/normasRESUMEN
BACKGROUND: Private hospital rooms have a number of potential advantages compared to shared rooms, including reduced noise and increased control over the hospital environment. However, the association of room type with patient experience metrics in total joint arthroplasty (TJA) patients is currently unclear. METHODS: For private versus shared rooms, we compared our institutional Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in patients who underwent primary TJA over a 2-year period. Regression model odds ratios (ORs) were adjusted for surgeon, date of surgery, and length of stay. RESULTS: Patients in private rooms were more likely to report a top-box score for overall hospital rating (85.6% vs 79.4%, OR = 1.53, P = .011), hospital recommendation (89.3% vs 83.0%, OR = 1.78, P = .002), call button help (76.0% vs 68.7%, OR = 1.40, P = .028), and quietness (70.4% vs 59.0%, OR = 1.78, P < .001). There were no significant differences on surgeon metrics including listening (P = .225), explanations (P = .066), or treatment with courtesy and respect (P = .396). CONCLUSION: For patients undergoing TJA, private hospital rooms were associated with superior performance on patient experience metrics. This association appears specific for global and hospital-related metrics, with little impact on surgeon evaluations. With the utilization of HCAHPS data in value-based initiatives, placement of TJA patients in private rooms may lead to increased reimbursement and higher hospital rankings. LEVEL OF EVIDENCE: Level III, retrospective cohort.
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Artroplastia de Reemplazo de Cadera/psicología , Artroplastia de Reemplazo de Rodilla/psicología , Pacientes Internos/psicología , Satisfacción del Paciente/estadística & datos numéricos , Habitaciones de Pacientes , Artroplastia , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Personal de Salud , Hospitales , Humanos , Pacientes Internos/estadística & datos numéricos , Estudios RetrospectivosRESUMEN
OBJECTIVE: Few have compared short-term outcomes following knee dislocations with or without concomitant popliteal artery disruption (PAD). METHODS: The Nationwide Inpatient Sample was used to identify 2175 patients admitted for knee dislocation from 2005 to 2013 (concomitant PAD: nâ¯=â¯210/9.7%; without: nâ¯=â¯1965/90.3%). RESULTS: Patients with PAD were younger, more often male, Black and Hispanic, and with Medicaid (all pâ¯≤â¯0.013). PADs were associated with 11.0-times higher odds of increased LOS (95%CI, 6.6-18.4) and 2.8-times higher odds of experiencing any complication (95%CI, 2.03-3.92). Female sex was a protective factor against increased LOS, (ORâ¯=â¯0.65; 95%CI, 0.48-0.88). CONCLUSION: High suspicion index should be maintained for concomitant vascular injuries following knee dislocations.
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In recent years, narcotics have been subject to increased regulation and monitoring because of their side effects and potential for misuse. Currently, variation in prescribing patterns of narcotics among orthopedic surgeons is unknown. The Medicare Part D claims database was used to identify orthopedic surgeons who prescribed at least one schedule II or III narcotic during 2014. The median duration of a narcotic prescription was 8.2 days. The median prescription duration was shortest for hand surgeons (5.6 days) and longest for spine surgeons (12.6 days). Orthopedic surgeons in New York (10.1 days) provided the most narcotics per prescription, with physicians in Vermont (6.2 days) providing the least. Substantial variation exists in narcotic prescribing patterns for orthopedic surgeons at the individual, subspecialty, and statewide levels. With public health focus on reducing narcotics abuse, physician stewardship of these medications will become increasingly relevant.
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Medicare Part D , Narcóticos/uso terapéutico , Cirujanos Ortopédicos , Pautas de la Práctica en Medicina , Bases de Datos Factuales , Prescripciones de Medicamentos , Humanos , New York , Estados UnidosRESUMEN
BACKGROUND: The number of periprosthetic proximal femoral fractures is expected to increase with the increasing prevalence of hip arthroplasties. While native hip fractures have a well-known association with mortality, there are currently limited data on this outcome among the subset of patients with periprosthetic proximal femoral fractures. METHODS: Using the New York Statewide Planning and Research Cooperative System, we identified patients from 60 to 99 years old who were admitted to a hospital in the state with a periprosthetic proximal femoral fracture (n = 1,655) or a native hip (femoral neck or intertrochanteric) fracture (n = 97,231) between 2006 and 2014. Within the periprosthetic fracture cohort, the indication for the existing implant was not available in the data set. We used mixed-effects regression models to compare mortality at 1 and 6 months and 1 year for periprosthetic compared with native hip fractures. RESULTS: The risk of mortality for patients who sustained a periprosthetic proximal femoral fracture was no different from that for patients who sustained a native hip fracture at 1 month after injury (3.2% versus 4.6%; odds ratio [OR], 0.90; 95% confidence interval [CI], 0.68 to 1.19; p = 0.446), but was lower at 6 months (3.8% versus 6.5%; OR, 0.74; 95% CI, 0.57 to 0.95; p = 0.020) and 1 year (9.7% versus 15.9%; OR, 0.71; 95% CI, 0.60 to 0.85; p < 0.001). Among periprosthetic proximal femoral fractures, factors associated with a significantly increased risk of mortality at 1 year included advanced age, male sex, and higher Deyo comorbidity scores. CONCLUSIONS: In the acute phase, any type of hip fracture appears to confer a similar risk of death. Over the long term, however, periprosthetic proximal femoral fractures are associated with lower mortality rates than native hip fractures, even after accounting for age and comorbidities. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fracturas de Cadera/mortalidad , Fracturas Periprotésicas/mortalidad , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , New York/epidemiología , Reoperación/estadística & datos numéricos , Factores de RiesgoRESUMEN
BACKGROUND: Patient satisfaction is publicly reported and used as a subjective measure of quality of care in alternative payment reimbursement models. In this study, we evaluated the association between patient satisfaction scores and objective measures of geriatric hip fracture care. Therefore, according to patient satisfaction score, we investigated the differences for geriatric hip fracture admissions in regard to 1. surgical delay during the index admission and 2. mortality within 1 year. METHODS: We identified 65,974 patients between the ages of 60 and 99 years with a primary diagnosis of femoral neck fracture in the New York Statewide Planning and Research Cooperative System database from 2009 to 2014. We evaluated patient satisfaction using annual hospital HCAHPS scores reported on Hospital Compare. Mixed effects regression models controlled for hospital and year of surgery as random effects variables and categorical age, sex, race, insurance, categorical Deyo score, fracture location, and surgical procedure as fixed effects variables. RESULTS: For high compared to low patient satisfaction hospitals, there were shorter surgical delays (ß: -60%, 95% CI: -66% to -52%, p < 0.001) and a lower risk of 1-year mortality (OR: 0.86, 95% CI: 0.78 to 0.93, p < 0.001). For middle compared to low patient satisfaction hospitals, there were shorter surgical delays (ß: -37%, 95% CI: -46% to -26%, p < 0.001), but no significant difference in 1-year mortality (OR: 0.94; 95% CI: 0.87 to 1.01; p = 0.091). CONCLUSIONS: Subjective quality, as measured by HCAHPS patient satisfaction scores, is associated with objective quality and clinical outcomes in geriatric hip fracture care. While these findings support the use of patient experience as a component of quality measurement, it remains unclear whether a superior patient experience in itself can increase the value of health care for patients in the form of superior clinical outcomes or if it will lead to increased strain on hospital resources and increase the cost of services, which would paradoxically decrease the value of care.
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Fracturas del Cuello Femoral , Fijación de Fractura , Satisfacción del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Anciano , Anciano de 80 o más Años , Femenino , Fracturas del Cuello Femoral/economía , Fracturas del Cuello Femoral/epidemiología , Fracturas del Cuello Femoral/cirugía , Fijación de Fractura/efectos adversos , Fijación de Fractura/métodos , Gastos en Salud , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , New York/epidemiología , Evaluación de Procesos y Resultados en Atención de SaludRESUMEN
The Comprehensive Care for Joint Replacement (CJR) model seeks to lower costs and improve quality for primary lower extremity joint replacements. This includes total ankle arthroplasty (TAA), which is performed far less frequently than total hip (THA) and knee (TKA) arthroplasty. We used the SPARCS database to identify 537 TAA and 239,053 elective primary THA or TKA procedures from 2009 to 2014, excluding hip fractures. Compared with THA and TKA, TAA had a shorter mean length of stay (2.2 versus 3.2 days), greater mean cost ($20,817 versus $17,613), lower rate of disposition to nursing and rehabilitation facilities (17% versus 52%), and lower rate of 90-day readmission (4.9% versus 5.8%). In multivariable-adjusted regression models of TAA versus THA and TKA, length of stay was 30% shorter (p < .001), costs were 14% greater (p < .001), and risk of disposition to nursing and rehabilitation facilities was 86% lower (p < .001), with no significant difference in 90-day readmission (p = .957). Patients undergoing TAA had different patterns of short-term resource usage compared with patients undergoing THA and TKA, most notably higher short-term costs. The economic viability of TAA is threatened by alternative payment models that reimburse hospitals for TAA at the same rate as THA and TKA.
Asunto(s)
Artroplastia de Reemplazo de Tobillo/economía , Atención Integral de Salud/economía , Costos de Hospital , Garantía de la Calidad de Atención de Salud/economía , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Tobillo/métodos , Artroplastia de Reemplazo de Cadera/economía , Artroplastia de Reemplazo de Cadera/métodos , Artroplastia de Reemplazo de Rodilla/economía , Artroplastia de Reemplazo de Rodilla/métodos , Centers for Medicare and Medicaid Services, U.S./economía , Estudios de Cohortes , Atención Integral de Salud/organización & administración , Bases de Datos Factuales , Femenino , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Estados UnidosRESUMEN
BACKGROUND: Atrial septal defect (ASD) and patent foramen ovale (PFO) are 2 of the most common congenital heart diseases in adults and pose important risks of perioperative acute ischemic stroke (AIS) from paradoxical emboli. We evaluated the following: (1) the prevalence of ASD/PFO in the total hip arthroplasty (THA) population; (2) the rate of perioperative AIS during index admissions; and (3) the risk for perioperative AIS after THA for patients with ASD/PFO vs matched controls. METHODS: We identified 393,652 patients in the Nationwide Inpatient Sample who underwent THA between January 1, 2007, and December 31, 2013. The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were used to identify patients with ASD/PFO and perioperative AIS. Propensity scores matched 252 patients with ASD/PFO to 756 controls (3:1 ratio) without ASD/PFO according to age, gender, race, Deyo comorbidity score, year of surgery, and stroke risk factors. Logistic regression models assessed risk for perioperative AIS. RESULTS: The prevalence of ASD/PFO was 64 per 100,000 THA patients. The rate of perioperative AIS was 99 per 100,000 THA in the general THA population. The rate of perioperative AIS was 7.14% for ASD/PFO patients compared with 0.26% in matched controls (P < .001). Risk for perioperative AIS was 29 times greater for patients with ASD/PFO compared with matched controls (odds ratio, 29.00; 95% confidence interval, 6.68-125.89; P < .001). CONCLUSION: Patients with ASD/PFO undergoing THA are at a significantly higher risk of perioperative AIS. Orthopedic surgeons should discuss this risk with patients before surgery. The efficacy of mechanical and pharmacologic thromboprophylactic measures to reduce perioperative AIS among ASD/PFO patients warrants further investigation.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Isquemia Encefálica/etiología , Foramen Oval Permeable/complicaciones , Complicaciones Posoperatorias/etiología , Accidente Cerebrovascular/etiología , Anciano , Isquemia Encefálica/epidemiología , Estudios de Casos y Controles , Comorbilidad , Femenino , Foramen Oval Permeable/epidemiología , Humanos , Modelos Logísticos , Masculino , Oportunidad Relativa , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Although resident physicians play a vital role in the US health care system, they are believed to create inefficiencies in the delivery of care. Under the regional component of the Comprehensive Care for Joint Replacement model, teaching hospitals are forced to compete on efficiency and outcomes with nonteaching hospitals. METHODS: We identified 86,021 patients undergoing elective primary total hip arthroplasty in New York State between January 1, 2009, and September 30, 2014. Outcomes included length and cost of the index admission, disposition, and 90-day readmission. Mixed-effects regression models compared teaching vs nonteaching orthopedic hospitals after adjusting for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients undergoing surgery at teaching hospitals had longer lengths of stay (ß = 3.2%; P < .001) and higher costs of admission (ß = 13.6%; P < .001). There were no differences in disposition status (odds ratio = 1.03; P = .779). The risk of 90-day readmission was lower for teaching hospitals (odds ratio = 0.89; P = .001). CONCLUSION: Primary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission. This suggests that teaching hospitals may be adversely affected by reimbursement tied to competition on economic and clinical metrics. Although a certain level of inefficiency is inherent during the learning process, these policies may hinder learning opportunities for residents in the clinical setting.