Timing of Readmissions After Elective Total Hip and Knee Arthroplasty: Does a 30-Day All-Cause Rate Capture Surgically Relevant Readmissions?

BACKGROUND: The 30-day all-cause readmission rate is a widely used metric of hospital performance. However, there is lack of clarity as to whether 30 days is an appropriate time frame following surgical procedures. Our aim is to determine whether a 90-day time window is superior to a 30-day time window in capturing surgically relevant readmissions after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We analyzed readmissions following all primary THAs and TKAs recorded in the English National Health Service Hospital Episode Statistics database from 2008 to 2018. We compared temporal patterns of 30- and 90-day readmission rates for the following types of readmission: all-cause, surgical, return to theater, and those related to specific surgical complications. RESULTS: A total of 1.47 million procedures were recorded. After THA and TKA, over three-quarters of 90-day surgical readmissions took place within the first 30 days (78.5% and 75.7%, respectively). All-cause and surgical readmissions both peaked at day 4 and followed a similar temporal course thereafter. The ratio of surgical to medical readmissions was greater for THA than for TKA, with THA dislocation both being one of the most common surgical complications and clustering early after discharge, with 73.5% of 90-day dislocations occurring within the first 30 days. CONCLUSION: The 30-day all-cause readmission rate is a good reflection of surgically relevant readmissions that take place in the first 90 days after THA and TKA.

The Validity of All-Cause 30-Day Readmission Rate as a Hospital Performance Metric After Primary Total Hip and Knee Arthroplasty: A Systematic Review.

BACKGROUND: Risk-adjusted all-cause 30-day readmission rate (ACRR) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is currently used as a metric of hospital performance as part of the Hospital Readmissions Reduction Program. However, the extent to which it is determined by hospital-related factors and is therefore a fair method of determining reimbursement remains unclear. METHODS: Our aim was to systematically review the available literature pertaining to whether ACRR is a valid metric of hospital performance after elective primary THA or TKA as determined by (1) its association with other performance metrics, (2) the extent to which variation in ACRR can be explained by between-hospital variation, and (3) the relative importance of hospital-related versus surgeon- or patient-related factors in determining ACRR. The MEDLINE, EMBASE, and Health Management Information Consortium databases were searched from inception to November 2018 and reference lists of selected articles scanned. The final list of articles was determined by consensus. RESULTS: Eight articles were included. Correlation of ACRR with established composite metrics of both outcome and process measures was poor. There was a weak positive correlation between ACRR and mortality. Only 1.5% of the variation in readmission rates for THA and TKA was found to be attributable to hospital-level factors, with patient-related factors such as age and comorbidities having much greater influence. Use of composite outcome metrics, for example, combining readmission and mortality, or considering the "surgical" readmission rate, improved the sensitivity to detect important between-hospital variation. CONCLUSION: There is insufficient evidence in the current literature to justify the use of ACRR following elective THA and TKA for financially penalizing hospitals. Further work is needed to define what is acceptable variation. The use of a composite metric or surgical readmission rate may improve the ability to detect between-hospital variation.

Predictors of 30-Day Readmission After Total Knee Arthroplasty: Analysis of 566,323 Procedures in the United Kingdom.

BACKGROUND: All-cause 30-day readmission after total knee arthroplasty (TKA) is currently used as a measure of hospital performance in the United States and elsewhere. Readmissions from surgical causes may more accurately reflect preventability and costs. However, little is known about whether predictors of each type of readmission differ. METHODS: All primary TKAs recorded in England's National Health Service administrative database from 2006 to 2015 were included. Multilevel logistic regression analysis was used to describe the effects of patient-related factors on 30-day readmission risk using 3 different readmission metrics: all-cause, surgical (defined using International Classification of Disease-10 primary admission diagnoses), and those resulting in return to theater (RTT). RESULTS: In total, 566,323 procedures were recorded. The comorbidity with the highest odds ratio (OR) for all types of readmission was psychoses (RTT OR 2.52, P < .001). Obesity was a strong independent predictor of RTT (OR 1.36, P < .001) and had the highest population attributable fraction of any comorbidity (4.7%). Unicompartmental arthroplasty was associated with a significantly lower risk of all types of readmission when compared with TKA, with the effect being most pronounced for surgical readmission (OR 0.66, P < .001). RTT in the index episode increased the risk of RTT readmission (OR 2.80, P < .001), as did any emergency admission to hospital in the preceding 12 months (for >2 emergency admissions, all-cause OR 2.38, P < .001). Length of stay either more than or less than 2 days was associated with an increased risk of all-cause and surgical readmission but not RTT readmission. CONCLUSION: Patient-related predictors of surgical and RTT readmission following TKA differ from those for all-cause readmission, but only the latter metric is in widespread use.

Comparison of 3 Types of Readmission Rates for Measuring Hospital and Surgeon Performance After Primary Total Hip and Knee Arthroplasty.

BACKGROUND: All-cause 30-day hospital readmission is in widespread use for monitoring and incentivizing hospital performance for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, little is known on the extent to which all-cause readmission is influenced by hospital or surgeon performance and whether alternative measures may be more valid. METHODS: This is an observational study using multilevel modeling on English administrative data to determine the interhospital and intersurgeon variation for 3 readmission metrics: all-cause, surgical, and return-to-theater. Power calculations estimated the likelihood of identifying whether the readmission rate for a surgeon or hospital differed from the national average by a factor of 1.25, 1.5, 2, or 3 times, for both average and high-volume providers. RESULTS: 259,980 THAs and 311,033 TKAs were analyzed. Variations by both surgeons and hospitals were smaller for the all-cause measure than for the surgical or return-to-theater metrics, although statistical power to detect differences was higher. Statistical power to detect surgeon-level rates of 1.25 or 1.5 times the average was consistently low. However, at the hospital level, the surgical readmission measure showed more variation by hospital while maintaining excellent power to detect differences in rates between hospitals performing the average number of THA or TKA cases per year in England. In practice, more outliers than expected from purely random variation were found for all-cause and surgical readmissions, especially at hospital level. CONCLUSION: The 30-day surgical readmission rate should be considered as an adjunctive measure to 30-day all-cause readmission rate when assessing hospital performance.

Strategies to Improve Start Time in the Operating Theatre: a Systematic Review.

Operating theatres represent a significant cost burden for healthcare providers around the world. Theatre start time is widely acknowledged as an important target for efficiency savings. However, there is uncertainty surrounding the effectiveness of strategies to improve start time, and questions regarding the barriers to their implementation. We conducted a systematic review of bibliographic databases to identify primary research papers assessing the effect of interventions on theatre start time. Two hundred and nine papers were found from electronic literature search with 14 being included in the final review. Financial incentives, educational approaches, system-based techniques, communication, the 'golden patient' initiative and 'the productive operating theatre' scheme have all been shown to improve start time. However, questions remain over which is the most effective, the longevity of their effects and whether the results can be extrapolated beyond the context in which they were studied. We summarise the key approaches reported in the literature and identify areas for future research. This is of use to clinicians and hospital managers seeking to improve efficiency and achieve cost savings.

Outcomes of total hip arthroplasty in haemodialysis and renal transplant patients: systematic review.

BACKGROUND: Chronic renal failure is increasing in prevalence and reported to have deleterious effects on the outcome of total hip arthroplasty (THA). AIM: To investigate the clinical and functional outcomes of THA in patients receiving haemodialysis or who have previously undergone renal transplantation. METHODS: Systematic review of the literature using bibliographic databases up to July 2018 to determine the functional outcome, complications and revision rates of THA in patients receiving haemodialysis for end-stage renal failure and those with a previous renal transplant. RESULTS: 25 studies were identified with a total of 797 THAs. 166 patients (20.8%) were receiving haemodialysis and 631 patients (79.2%) had undergone transplantation. All studies reported a marked improvement in hip function following THA. There were 27 failures (15.7% revision rate) in the haemodialysis group and 101 failures (16.0% revision rate) in the transplant group. The revision rate for cemented implants was higher in haemodialysis versus transplant patients (23% vs. 15%), with the converse being true for uncemented implants (3.8% vs. 6.9%). The deep infection rate was higher in the haemodialysis group (10.8% vs. 2.1%). CONCLUSIONS: Patients receiving haemodialysis or with a history of renal transplantation can expect good functional outcome following THA. However, the revision rate and deep infection rate are higher than would be expected in patients receiving THA for primary OA. Aseptic loosening is the most common reason for revision. Uncemented implants appear to be associated with lower failure rates both in haemodialysis patients and those who have had a transplant.

Surgical treatment of an ischial tuberosity avulsion fracture with delayed presentation.

Avulsion fractures of the ischial tuberosity usually occur in skeletally immature athletes following eccentric contraction of the hamstrings. When displaced fractures are left untreated, subsequent non-union and proximal hamstring fibrosis may lead to chronic pain and reduced activity. However, the indications for and outcomes of operative fixation when presentation is delayed remain unclear. We report the case of a 14 year old male athlete who presented to our institution 6 weeks after sustaining a displaced ischial tuberosity avulsion fracture. He underwent open reduction and internal fixation using a cannulated screw system via a posterior approach, with excellent results at 18 months follow-up. We report our surgical findings in detail as well as a novel method for post-operatively assessing functional screw head prominence-the seated radiograph.

The prevalence and impact of gender bias and sexual discrimination in orthopaedics, and mitigating strategies.

AIMS: Gender bias and sexual discrimination (GBSD) have been widely recognized across a range of fields and are now part of the wider social consciousness. Such conduct can occur in the medical workplace, with detrimental effects on recipients. The aim of this review was to identify the prevalence and impact of GBSD in orthopaedic surgery, and to investigate interventions countering such behaviours. METHODS: A systematic review was conducted by searching Medline, EMCARE, CINAHL, PsycINFO, and the Cochrane Library Database in April 2020, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to which we adhered. Original research papers pertaining to the prevalence and impact of GBSD, or mitigating strategies, within orthopaedics were included for review. RESULTS: Of 570 papers, 27 were eligible for inclusion. These were published between 1998 and 2020. A narrative review was performed in light of the significant heterogeneity displayed by the eligible studies. A total of 13 papers discussed the prevalence of GBSD, while 13 related to the impact of these behaviours, and six discussed mitigating strategies. GBSD was found to be common in the orthopaedic workplace, with all sources showing women to be the subjects. The impact of this includes poor workforce representation, lower salaries, and less career success, including in academia, for women in orthopaedics. Mitigating strategies in the literature are focused on providing female role models, mentors, and educational interventions. CONCLUSION: GBSD is common in orthopaedic surgery, with a substantial impact on sufferers. A small number of mitigating strategies have been tested but these are limited in their scope. As such, the orthopaedic community is obliged to participate in more thoughtful and proactive strategies that mitigate against GBSD, by improving female recruitment and retention within the specialty. Cite this article: Bone Joint J 2020;102-B(11):1446-1456.

The prevalence and impact of gender bias and sexual discrimination in orthopaedics, and mitigating strategies.

AIMS: Gender bias and sexual discrimination (GBSD) have been widely recognized across a range of fields and are now part of the wider social consciousness. Such conduct can occur in the medical workplace, with detrimental effects on recipients. The aim of this review was to identify the prevalence and impact of GBSD in orthopaedic surgery, and to investigate interventions countering such behaviours. METHODS: A systematic review was conducted by searching Medline, EMCARE, CINAHL, PsycINFO, and the Cochrane Library Database in April 2020, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to which we adhered. Original research papers pertaining to the prevalence and impact of GBSD, or mitigating strategies, within orthopaedics were included for review. RESULTS: Of 570 papers, 27 were eligible for inclusion. These were published between 1998 and 2020. A narrative review was performed in light of the significant heterogeneity displayed by the eligible studies. A total of 13 papers discussed the prevalence of GBSD, while 13 related to the impact of these behaviours, and six discussed mitigating strategies. GBSD was found to be common in the orthopaedic workplace, with all sources showing women to be the subjects. The impact of this includes poor workforce representation, lower salaries, and less career success, including in academia, for women in orthopaedics. Mitigating strategies in the literature are focused on providing female role models, mentors, and educational interventions. CONCLUSION: GBSD is common in orthopaedic surgery, with a substantial impact on sufferers. A small number of mitigating strategies have been tested but these are limited in their scope. As such, the orthopaedic community is obliged to participate in more thoughtful and proactive strategies that mitigate against GBSD, by improving female recruitment and retention within the specialty.

Paediatric supracondylar humerus fractures.

This article gives a practical guide to the management of supracondylar fractures of the humerus in paediatric patients, from initial presentation to definitive treatment. It reviews the optimal management of this common and serious injury based on current evidence including the British Orthopaedic Association Standards for Trauma (BOAST) 11 standard.

Vertebral compression fractures.

This review gives a practical guide to the investigation and management of osteoporotic vertebral compression fractures. With an ageing population, the burden of disease and health system costs attributable to this common injury continue to rise. This article outlines the epidemiology, clinical and radiological assessment of vertebral compression fractures, and key decisions that must be made in their management. It reviews the indications and evidence for conservative vs operative treatment, discusses the rationale for vertebroplasty, kyphoplasty and spinal stabilization, and looks at outcomes in this vulnerable patient population. It also reviews key evidence underlying decision making including National Institute for Health and Care Excellence guidelines.

Immobilisation in occipital condyle fractures: A systematic review.

OBJECTIVES: The objectives of this review are to determine the level of evidence for the management of OCF, compare outcomes of different immobilisation, and to review the prognosis. PATIENTS AND METHODS: A literature search was conducted using 3 databases (MEDLINE, PubMed and EMBASE). All papers between 1940 and July 2017 were screened using PRISMA guidelines. Inclusion criteria were patients with a confirmed diagnosis of occipital condyle fracture(s) on CT managed with any form of immobilisation with no age restriction. Primary outcome was clinical improvement in symptoms or Neck Disability Index. MINORS and OCEBM level was assigned to each study. RESULTS: 25 studies met the inclusion criteria. Most studies used a single form of C-spine immobilisation support (58%) with a semi rigid collar and halo device being the most common. From these studies, the average length of time for immobilisation was 11.7 weeks, 9 weeks and 8.3 weeks for halo, semi-rigid and rigid cervical collars respectively. Neuro deficit was found in 20.3% of patients. OCEBM level of evidence and MINORS score was low. CONCLUSION: Management of OCF is associated with low level of evidence. Further studies are needed to determine optimal management of these under-diagnosed fractures.

Predictors of 30-day hospital readmission after hip fracture: a systematic review.

BACKGROUND: Early readmission to hospital after hip fracture is associated with increased mortality and significant costs to the healthcare system. There is growing interest in the use of 30-day readmission rates as a metric of hospital performance. Identifying patients at increased risk of readmission after hip fracture may enable pre-emptive action to mitigate this risk and the development of effective methods of risk-adjustment to allow readmission to be used as a reliable measure of hospital performance. METHODS: We conducted a systematic review of bibliographic databases and reference lists up to July 2016 to identify primary research papers assessing the effect of patient- and hospital-related risk factors for 30-day readmission to hospital after hip fracture. RESULTS: 495 papers were found through electronic and reference search. 65 full papers were assessed for eligibility. 22 met inclusion criteria and were included in the final review. Medical causes of readmission were significantly more common than surgical causes, with pneumonia consistently being cited as the most common readmission diagnosis. Age, pre-existing pulmonary disease and neurological disorders were strong independent predictors of readmission. ASA grade and functional status were more robust predictors of readmission than the Charlson score or individual co-morbidities. Hospital-related risk factors including initial length of stay, hospital size and volume, time to surgery and type of anaesthesia did not have a consistent effect on readmission risk. Discharge location and the strength of hospital-discharge facility linkage were important determinants of risk. CONCLUSIONS: Patient-related risk factors such as age, co-morbidities and functional status are stronger predictors of 30-day readmission risk after hip fracture than hospital-related factors. Rates of 30-day readmission may not be a valid reflection of hospital performance unless a clear distinction can be made between modifiable and non-modifiable risk factors. We identify a number of deficiencies in the existing literature and highlight key areas for future research.

Factors Associated With 30-Day Readmission After Primary Total Hip Arthroplasty: Analysis of 514 455 Procedures in the UK National Health Service.

IMPORTANCE: Thirty-day readmission to hospital after total hip arthroplasty (THA) has significant direct costs and is used as a marker of hospital performance. All-cause readmission is the only metric in current use, and risk factors for surgical readmission and those resulting in return to theater (RTT) are poorly understood. OBJECTIVE: To determine whether patient-related predictors of all-cause, surgical, and RTT readmission after THA differ and which predictors are most significant. DESIGN, SETTING, AND PARTICIPANTS: Analysis of all primary THAs recorded in the National Health Service (NHS) Hospital Episode Statistics database from 2006 to 2015. The effect of patient-related factors on 30-day readmission risk was evaluated by multilevel logistic regression analysis. The analysis comprised all acute NHS hospitals in England and all patients receiving primary THA. MAIN OUTCOMES AND MEASURES: Thirty-day readmission rate for all-cause, surgical (defined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision primary admission diagnoses), and readmissions resulting in RTT. RESULTS: Across all hospitals, 514 455 procedures were recorded. Seventy-nine percent of patients were older than 60 years, 40.3% were men, and 59.7% were women. There were 30 489 all-cause readmissions (5.9%), 16 499 surgical readmissions (3.2%), and 4286 RTT readmissions (0.8%); 54.1% of readmissions were for surgical causes. Comorbidities with the highest odds ratios (ORs) of RTT included those likely to affect patient behavior: drug abuse (OR, 2.22; 95% CI, 1.34-3.67; P = .002), psychoses (OR, 1.83; 95% CI, 1.16-2.87; P = .009), dementia (OR, 1.57; 95% CI, 1.11-2.22; P = .01), and depression (OR, 1.52; 95% CI, 1.31-1.76; P < .001). Obesity had a strong independent association with RTT (OR, 1.46; 95% CI, 4.45-6.43; P < .001), with one of the highest population attributable fractions of the comorbidities (3.4%). Return to theater in the index episode was associated with a significantly increased risk of RTT readmission (OR, 5.35; 95% CI, 4.45-6.43; P < .001). Emergency readmission to the hospital in the preceding 12 months increased the risk of readmission significantly, with the association being most pronounced for all-cause readmission (for >2 emergency readmissions, OR, 2.33; 95% CI, 2.11-2.57; P < .001). Hip resurfacing was associated with a lower risk of RTT when compared with cemented implants (OR, 0.69; 95% CI, 0.54-0.88; P = .002) but for other types of readmission, implant type had no significant association with readmission risk. Increasing age and length of stay were strongly associated with all-cause readmission. CONCLUSIONS AND RELEVANCE: Many patient-related risk factors for surgical and RTT readmission differ from those for all-cause readmission despite the latter being the only measure in widespread use. Clinicians and policy makers should consider these alternative readmission metrics in strategies for risk reduction and cost savings.

Does activity affect the outcome of the Oxford unicompartmental knee replacement?

BACKGROUND: High levels of activity are considered to be a contraindication to unicompartmental knee replacement (UKR) and are not recommended after UKR. To determine if these recommendations should apply to the mobile-bearing Oxford UKR, this study assessed the effect of post-operative activity level on the outcome of this device. METHODS: The outcome of the first 1000 Phase 3 cemented Oxford UKRs implanted between 1998 and 2010 was assessed using survival analysis, the Oxford Knee Score (OKS) and the American Knee Society Objective (KSS-O) and Functional (KSS-F) Scores. Patients were grouped according to the maximum post-operative Tegner Activity Score. RESULTS: The mean follow-up was 6.1 years (range 1 to 14). Overall, increasing activity was associated with superior survival (p=0.025). In the high activity group, with Tegner≥5 (n=115) 2.6% were revised and the 12-year survival was 97.3% (confidence interval (CI): 92.0% to 99.1%). In the low activity group, with Tegner≤4, (n=885) 4.3% were revised and the 12-year survival was 94.0% (CI: 91.4 to 95.8). The difference between the two groups was not significant (p=0.44). Although the final OKS and KSS-F were significantly better in the high activity group compared to the low activity group (OKS 45v40, KSS-F 95v78), there was no difference in the change in OKS or KSS-O. CONCLUSIONS: High activity does not compromise the outcome of the Oxford UKR and may improve it. Activity should not be restricted nor considered to be a contraindication.