Postoperative pain score does not correlate with injury severity in isolated tibial plateau fractures.

PURPOSE: Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative pain score correlates with injury severity in tibial plateau fractures. METHODS: A retrospective review of prospectively collected data was completed at a single academic level one trauma center. All adult patients treated operatively for tibial plateau fractures who did not have concomitant injuries, previous injury to the ipsilateral tibia or knee joint, compartment syndrome, inadequate follow-up, or perioperative regional anesthesia were included (n = 88). The patients were split into groups based on the AO/OTA fracture classification (B-type vs C-type), energy mechanism, number of surgical approaches, need for temporizing external fixation, and operative time as a proxy for injury severity. The primary outcome measure was the visual analog scale (VAS) pain score (average in the first 24 h, highest in the first 24 h, two- and six-week postoperative appointments). Psychosocial and comorbid factors that may affect pain were studied and controlled for (history of diabetes, neuropathy, anxiety, depression, PTSD, and previous opioid prescription). Additionally, opioid use in the postoperative period was studied and controlled for (morphine milligram equivalents (MME) administered in the first 24 h, discharge MME/day, total discharge MME, and opioid refills). RESULTS: VAS scores were similar between groups at each time point except the two-week postoperative time point. At the two-week postoperative time point, the absolute difference between the groups was 1.3. The groups were significantly different in several injury and surgical variables as expected, but were similar in all demographic, comorbid, and postoperative opioid factors. CONCLUSIONS: There was no clinical difference in postoperative pain between AO/OTA 41B and 41C tibial plateau fractures. This supports the idea of providers uncoupling nociception and pain in postoperative patients. Providers should consider minimizing extended opioid use, even in more severe injuries.

The use of causal language and inferences in observational shoulder arthroplasty database studies.

BACKGROUND: Over the last few decades, several databases and clinical registries have been used to generate studies for orthopedic surgery research including shoulder arthroplasty. Observational database studies present data that are best used to provide information regarding associations between variables but is unable to prove causation. Yet, there remains a tendency for authors to use causal language and conclusive statements in published shoulder arthroplasty literature using such databases. METHODS: We systematically identified administrative database and registry studies on shoulder arthroplasty in 5 orthopedic journals from January 2020 to December 2021. Papers were independently graded by 2 reviewers for the presence, absence, or inconsistent use of causal language throughout the publication. χ2 analyses were conducted to determine the relationship between causality language and article characteristics including the journal of publication. RESULTS: There were 65 eligible articles. According to the reviewers, 67.7% of titles and abstracts were either consistently causal or inconsistently causal in language and inference. On reviewing the full text, 69.2% were found to contain some degree of causal language (38.5% consistently causal, 30.8% inconsistently causal). There were no statistically significant associations between the journal and title and abstract final grading (P = .863) or the journal and full-text grading (P = .726). CONCLUSION: The use of causal language remains highly prevalent in observational database studies related to shoulder arthroplasty. Understanding the limitations of observational database studies is paramount for accurate interpretation of these publications.

High Prevalence of Causal Language and Inferences in Observational Hip and Knee Arthroplasty Database Studies: A Review of Papers Published Across Four Orthopaedic Journals.

BACKGROUND: The use of administrative databases and clinical registries in lower extremity arthroplasty research is growing. Such observational studies are unable to fully control for confounders and cannot establish causality. However, many authors use causal language when describing their aims or findings, potentially misleading readers. We examined the prevalence of causal language and inferences in the lower extremity arthroplasty literature. METHODS: We systematically identified administrative database and registry studies on hip and knee arthroplasty that were published in 4 orthopaedic journals in 2020. Articles were graded independently by two reviewers for the presence of causal language in both the title and abstract and the full text. Chi-squared analyses were conducted to determine the relationship between the causality grading and article characteristics including the journal of publication. RESULTS: Of 116 eligible articles, we classified 79.3% of titles and abstracts as either consistently causal or inconsistently causal, with only 20.7% as consistently noncausal. A total of 40.5% of full texts were consistently causal, 49.1% were inconsistent, and 10.3% were consistently noncausal. Chi-squared analyses revealed no statistically significant association between the title and abstract's grading and the journal (P = .720) nor with the use of a database or registry (P = .716). CONCLUSION: Causal language and inferences were present in 79.3% of titles and abstracts of lower extremity arthroplasty observational database studies published in 2020. The high prevalence of causal language and inferences in the arthroplasty literature may mislead readers.

The Impact of Robotic-Assisted Total Knee Arthroplasty on Resident Training.

BACKGROUND: As robotic-assisted total knee replacement (rTKA) continues to gain popularity, the impact of this technology on resident education remains unknown. The purpose of this study was to describe trainee experience and perceptions of rTKA and its effect on surgical training. METHODS: Two hundred and twenty two senior orthopaedic residents attending a national board review course completed a 17-question survey regarding their experience and perceptions regarding rTKA. Mean and standard deviations were calculated for Likert scale questions, and bivariate analyses were utilized to compare answer groups. RESULTS: Seventy percent of respondents reported exposure to rTKA during their training. Of those with robotic exposure, 20% reported that greater than half of their TKA experience involved robotics. Only 29% percent agreed that robotics improved outcomes, whereas 21% disagreed and the remainder were unsure. Over half of respondents agreed that robotics are used primarily for marketing purposes. Of those who trained with rTKA, 45% percent believed that robotics improved their understanding of the surgical procedure; however, 25% felt robotics negatively compromised their training with traditional instrumentation. Higher robotic case exposure (P = .001) and attending an industry-sponsored course (P = .02) was associated with the belief that robotics improved outcomes. Robotic case volume and percentage was associated with the belief that robotics improved understanding of the surgical procedure, however, it also was associated with reduced comfort performing traditional knee arthroplasty (P = .001). CONCLUSION: Current resident training experience varies greatly within the United States with regards to rTKA. While exposure to rTKA may be beneficial for a well-rounded surgical education, over-exposure likely results in decreased comfort with traditional instrumentation.

Cost-Conscious Colposcopy: A Single-Institution Review of Biopsy Submission Practices and Outcomes.

OBJECTIVE: Distribution of cervical dysplasia may influence approach for excisional procedures. Separating colposcopy biopsies into multiple specimen cups for pathologic evaluation incurs additional costs. The authors aimed to determine whether the practice of separating biopsy specimens impacts patient outcomes. METHODS: A retrospective review of all colposcopy cases from a single institution was performed. A total of 1,331 cases were reviewed from January 1, 2017, to December 31, 2019. Multibiopsy cohorts were separated by number of specimen cups received by pathology (single or multiple). Cohorts were compared for histology, need for excisional procedure, and final excisional pathology results. Specimen processing fees were acquired from the Department of Pathology ($70/specimen). Statistical analysis performed on MINITAB using Pearson chi-square and Fisher exact tests. RESULTS: Excisional procedures were required by 30.4% (86/283) of multiple specimen submissions compared with 28.2% (154/547) of single specimen cup submissions ( p = .50). There was a higher, although not statistically significant, rate of additional procedures in the multiple specimen cup cohort (8.8 vs 2.9% [ p = .08]). Malignancy diagnosis was equivalent in each cohort. Cost analysis revealed adopting a single specimen cup model would reduce costs up to approximately $30,000/year. CONCLUSIONS: Patient outcomes were not improved by the practice of submitting multiple specimen cups. Given the additional cost associated with separating specimens, the authors recommend during routine colposcopy that all cervical biopsies be sent for evaluation as a single pathology specimen unless a lesion of concern is identified in an area not normally excised during traditional excisional procedures.

Static Non-articulating Knee Spacers Are Associated with a High Degree of Morbidity in Challenging Clinical Scenarios.

The morbidity associated with the use of static non-articulating knee spacers for the treatment of periprosthetic joint infection (PJI) in challenging clinical scenarios has not been well described. From 2011-2019, 63 molded block static spacers were utilized at two academic institutions for the treatment of PJI with associated severe soft tissue compromise (59%), collateral ligament deficiency (49%), extensor mechanism compromise (48%), or type 3 bone defects (44%). Complications and outcomes were assessed. Complications with the use of static spacers were common and included further bone loss (46%), spacer migration (16%), extensor mechanism compromise (16%), cast or related soft tissue injuries (16%), fracture (13%), and spacer breakage (3%). Ultimately, 22% of patients underwent amputation. Patient variables such as age and body mass index were not associated with outcomes. Static knee spacers are associated with substantial morbidity in challenging clinical scenarios and alternatives may need to be considered. (Journal of Surgical Orthopaedic Advances 32(2):122-126, 2023).

Regional anesthesia provides limited decreases in opioid use following distal tibia and ankle fracture surgery.

PURPOSE: Regional anesthesia (RA) is used for pain control, but its impacts on the orthopedic trauma population are not well known. This study evaluated the impact of peripheral nerve blocks after distal tibia and ankle fracture repair on opioid use and pain scores and quantified the magnitude and duration of any changes. METHODS: This retrospective cohort study included patients treated operatively for distal tibia and ankle fractures over a 5-year period, both with and without peripheral nerve blocks. Total inpatient 5 mg oxycodone equivalents (OEs) used in the post-operative period, from 0-24, 24-48, to 48-72 h and maximum visual analog scale (VAS) pain ratings from 0-24, 24-48, to 48-72 h were recorded. RESULTS: 540 non-polytrauma patients and 183 polytrauma patients were included. Patients in the non-polytrauma group who received nerve blocks required fewer opioids on post-operative day (POD) 1 compared to the non-nerve block group (4.8 [95% CI 4.2-5.4] vs. 10.5 [95% CI: 9.2-11.8]; p < 0.001) and had lower VAS scores on POD1 (5.0 [95% CI 4.6-5.4] vs. 7.7 [95% CI: 7.3-8.1]; p < 0.001). However, there were no differences between these groups on POD2 or POD3 and no differences at any timepoints in the polytrauma group. CONCLUSION: Patients with isolated distal tibia and ankle fractures who receive peripheral nerve blocks demonstrate modest reductions in inpatient opioids and pain scores on POD1. However, there are no clear benefits beyond this point. Furthermore, polytrauma patients do not experience any reductions in opioid consumption or pain scores.

Surgical delays of less than 1 year in Mohs surgery associated with tumor growth in moderately- and poorly-differentiated squamous cell carcinomas but not lower-grade squamous cell carcinomas or basal cell carcinomas: A retrospective analysis.

BACKGROUND: Evidence is controversial and limited concerning whether surgical delays are associated with tumor growth for cutaneous squamous cell carcinomas (SCCs) and basal cell carcinomas. OBJECTIVE: Identify tumor subpopulations that may demonstrate an association between tumor growth and surgical delay. METHODS: We retrospectively analyzed 299 SCCs and 802 basal cell carcinomas treated with Mohs surgery at a single institution. Time interval from biopsy to surgery represented surgical delay. Change in major diameter (ΔMD) from size at biopsy to postoperative defect represented tumor growth. Independent predictors of ΔMD were identified by multivariate analysis. Linear regression was then utilized to assess for whether the ΔMD from these independent predictors trended with surgical delay. RESULTS: Surgical delays ranged from 0 to 331 days. Among SCCs, histologic subtype and prior treatment were identified as independent predictors of ΔMD. Significant associations between ΔMD and surgical delay were found for poorly- and moderately-differentiated SCCs, demonstrating growth rates of 0.28 cm and 0.24 cm per month of delay, respectively. The ΔMD for SCCs with prior treatment and basal cell carcinoma subgroups did not vary with surgical delay. LIMITATIONS: Retrospective design, single center. CONCLUSION: Surgical delays of less than a year were associated with tumor growth for higher-grade SCCs, with effect sizes bearing potential for clinical significance.

The Association between Weather and Emergency Department Visitation for Diabetes in Roanoke, Virginia.

Diabetes mellitus imposes a significant and increasing health burden on the US population. Our objective is to determine if weather is related to daily variations in emergency department (ED) visits for diabetes mellitus in Roanoke, Virginia. A time series of daily ED visits for diabetes mellitus at the Carilion Clinic in southwestern Virginia is associated with daily minimum temperature from 2010-2017. Associations between ED visits (through a 14-day lag period) and temperature are examined using generalized additive models and distributed lag nonlinear models. Heat and cold waves are identified at low and high thresholds, and ED visitation during these events is compared to prior control periods using a time-stratified case crossover approach. ED visits for diabetes exhibit a U-shaped relationship with temperature, with a higher relative risk (RR) during cold events (RR = 1.05) vs. warm events (RR = 1.02). When minimum temperatures are below freezing, ED visitation peaks starting 2 days afterward, with RRs approaching 1.04. The RR on warm days (minimum temperature > 10 °C) approaches 1.02 but peaks on the day of or the day following the elevated temperatures. Cold waves increase the odds of ED visits by up to 11% (p = 0.01), whereas heat waves exhibit no significant effect (p = 0.07). The increasing health burden linked to diabetes requires new research on environmental factors that might exacerbate related illness. When examined in the context of climate change impacts on local weather variations, these kinds of linkages between environment and disease can aid in facility staffing and public health messaging during extreme weather events.

Are We Training Surgeons to Cement a Femoral Component in Hip Arthroplasty? The Trainees' Perspective.

BACKGROUND: The importance of surgical technique is widely recognized when cementing a femoral component in hip arthroplasty. Concern exists that surgeon trainees in the United States are not being adequately trained in cement technique. The purpose of this study is to describe recent trainees' perceived experience with their training in this skill. METHODS: Orthopedic graduate candidates attending a national board review course were polled with an anonymous 15-question survey regarding their experiences during training with cemented femoral components. Means and standard deviations were calculated for Likert scale questions, and univariate statistics were used to compare answers for select questions. RESULTS: A total of 152 surveys were completed. Ninety percent of respondents anticipated that they would be performing hemiarthroplasty for fracture in their future practice, 99% of whom anticipated using cement for stem fixation in at least some of these cases. Only a minority of respondents planned further training in an adult reconstruction fellowship (21%). Only 37% of residents perceived their training in cement technique to be comprehensive or very comprehensive, with 17% reporting that their training was inadequate or nonexistent. Forty percent reported being less than satisfied with their training. Although 96% of residents felt prepared to implant a cementless femoral component, only 82% felt adequately trained to properly cement a femoral implant. Feeling prepared to perform a well done cemented femoral stem correlated with higher percentage of cemented stems in training and higher satisfaction with training (both P = .001). CONCLUSION: Although most trainees feel prepared to cement a femoral component, many young surgeons do not perceive that they are receiving adequate training in femoral cement technique.

Treatment Decision Regret in Patients Who Develop Periprosthetic Joint Infection and Require Two-Stage Revision Surgery.

BACKGROUND: The decision to proceed with total joint arthroplasty (TJA) can be complex and requires an assessment of potential risks of surgery. Patients who experience the potentially devastating complication of periprosthetic joint infection (PJI) may have a poor outcome and wish they had never elected to have surgery. No study has examined decision regret related to the choice to pursue TJA in patients who develop PJI. METHODS: All patients who were treated for PJI with a two-stage revision at a tertiary academic medical center between 2010 and 2020 were surveyed. Ninety-six patients agreed to answer 12 questions concerning their understanding of their preoperative risk of infection and their level of regret with the decision to pursue index TJA. Patient regret was calculated using the Decision Regret Scale. RESULTS: Seventy-two percent of patients reported that their joint replacement and concomitant infection had a severe ongoing impact on their quality of life, although only 28% of respondents regretted their choice to undergo index TJA, and 65% would undergo TJA again. A higher Musculoskeletal Infection Society outcome stage (typically due to failed treatment) and lower understanding of joint infection were associated with a higher level of regret on the Decision Regret Scale (P < .001). CONCLUSION: Self-reported decisional regret was present in only 1 in 4 patients who underwent arthroplasty despite experiencing a devastating complication, and almost two-thirds of patients with PJI reported they would undergo primary TJA again. Patients who were more informed about infection before TJA experienced less regret when they subsequently developed PJI. LEVEL OF EVIDENCE: III.

The 2021 Association Research Circulation Osseous Classification for Early-Stage Osteonecrosis of the Femoral Head to Computed Tomography-Based Study.

BACKGROUND: The Association Research Circulation Osseous developed a novel classification for early-stage (precollapse) osteonecrosis of the femoral head (ONFH). We hypothesized that the novel classification is more reliable and valid when compared to previous 3 classifications: Steinberg, modified Kerboul, and Japanese Investigation Committee classifications. METHODS: In the novel classification, necrotic lesions were classified into 3 types: type 1 is a small lesion, where the lateral necrotic margin is medial to the femoral head apex; type 2 is a medium-sized lesion, with the lateral necrotic margin being between the femoral head apex and the lateral acetabular edge; and type 3 is a large lesion, which extends outside the lateral acetabular edge. In a derivation cohort of 40 early-stage osteonecrotic hips based on computed tomography imaging, reliabilities were evaluated using kappa coefficients, and validities to predict future femoral head collapse by chi-squared tests and receiver operating characteristic curve analyses. The predictability for future collapse was also evaluated in a validation cohort of 104 early-stage ONFH. RESULTS: In the derivation cohort, interobserver reliability (k = 0.545) and intraobserver agreement (63%-100%) of the novel method were higher than the other 3 classifications. The novel classification system was best able to predict future collapse (P < .05) and had the best discrimination between non-progressors and progressors in both the derivation cohort (area under the curve = 0.692 [0.522-0.863], P < .05) and the validation cohort (area under the curve = 0.742 [0.644-0.841], P = 2.46 × 10-5). CONCLUSION: This novel classification is a highly reliable and valid method of those examined. Association Research Circulation Osseous recommends using this method as a unified classification for early-stage ONFH. LEVEL OF EVIDENCE: Level III, diagnostic study.

Are Patients More Susceptible to Viral Illness Immediately Following Hip and Knee Arthroplasty? An Analysis of Influenza Diagnoses Using Multiple Administrative Databases.

BACKGROUND: Elective surgery elicits a systemic immune response and may result in transient immunosuppression in certain patients. It is currently unknown whether patients are at increased risk for viral infection and associated illness in the immediate postoperative period following total joint arthroplasty (TJA). METHODS: Four large administrative datasets (Medicare 5% and 100% standard analytic files, Humana claims, and Mariner Database) were analyzed to identify patients who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA) from 2005 to 2017. The influenza vaccination status of each patient was defined using the presence or absence of a code for vaccination. The incidence of an influenza diagnosis was recorded in both vaccinated and unvaccinated patients during peak influenza season following the date of surgery and compared to a cohort of vaccinated patients who did not undergo surgery. RESULTS: The incidence of postoperative influenza diagnoses in TKA and THA patients was similar to that of vaccinated patients who did not undergo TJA at all time points. The results were largely consistent across all datasets. CONCLUSION: Large administrative databases fail to show an increased incidence of influenza in patients who have recently undergone TJA. While the lack of signal in the data is reassuring, these findings are limited by the nature of large administrative datasets and the accuracy of coding for influenza. Further studies will be necessary to fully understand an individual patient's postoperative risk for contracting a viral illness. LEVEL OF EVIDENCE: Level III.

A comparison of the effect of weather and climate on emergency department visitation in Roanoke and Charlottesville, Virginia.

Compared with mortality, the impact of weather and climate on human morbidity is less well understood, especially in the cold season. We examined the relationships between weather and emergency department (ED) visitation at hospitals in Roanoke and Charlottesville, Virginia, two locations with similar climates and population demographic profiles. Using patient-level data obtained from electronic medical records, each patient who visited the ED was linked to that day's weather from one of 8 weather stations in the region based on each patient's ZIP code of residence. The resulting 2010-2017 daily ED visit time series were examined using a distributed lag non-linear model to account for the concurrent and lagged effects of weather. Total ED visits were modeled separately for each location along with subsets based on gender, race, and age. The relationship between the relative risk of ED visitation and temperature or apparent temperature over lags of one week was positive and approximately linear at both locations. The relative risk increased about 5% on warm, humid days in both cities (lag 0 or lag 1). Cold conditions had a protective effect, with up to a 15% decline on cold days, but ED visits increased by 4% from 2 to 5 days after the cold event. The effect of thermal extremes tended to be larger for non-whites and the elderly, and there was some evidence of a greater lagged response for non-whites in Roanoke. Females in Roanoke were more impacted by winter cold conditions than males, who were more likely to show a lagged response at high temperatures. In Charlottesville, males sought ED attention at lower temperatures than did females. The similarities in the ED response patterns between these two hospitals suggest that certain aspects of the response may be generalizable to other locations that have similar climates and demographic profiles.

Zip Codes May Not Be an Adequate Method to Risk Adjust for Socioeconomic Status Following Total Joint Arthroplasty at the Individual Surgeon Level.

BACKGROUND: Increasing consumerism in healthcare has included a push toward the ranking of individual surgeons. These rankings rely on the adjustment of patient outcomes based on individual patient risk. Socioeconomic status (SES) has been identified as an important variable impacting patient outcomes following total joint arthroplasty, and patient zip code has been proposed as a proxy. Our study attempts to determine if zip code is an acceptable proxy for SES within a single surgeon's practice. METHODS: Using public zip code and Geographic Information Systems (GIS) tax map data, we compared the real estate holdings of 244 patients undergoing total joint arthroplasty from an individual hip and knee arthroplasty surgeon's practice within an academic medical center over a 14-month period. An independent t-test was used to compare GIS data with the average home value within a given zip code. A Pearson correlation coefficient was calculated between GIS values and average home value per zip code. RESULTS: In a sample of 244 patients, mean home value calculated from GIS data was $335,993 (standard deviation [SD] $246,549), and $243,663 with zip code data (SD $84,731). The Pearson correlation coefficient was 0.411 (P < .001). There was a significant difference between mean home values calculated from zip code data and GIS data (P < .001). Using zip code estimates would have mischaracterized home value, as defined as greater than or less than 1 SD, in 15% of patients. CONCLUSION: Although there was some relationship between zip code and real estate holdings, the correlation is only moderate in strength and a substantial number of outliers were present. Given the sample size at the individual surgeon level, we question whether zip code can be used as a proxy for SES risk adjustment for the purposes of surgeon ranking.

Increasing Public Interest in Stem Cell Injections for Osteoarthritis of the Hip and Knee: A Google Trends Analysis.

BACKGROUND: Stem cell injections are being offered to patients as a nonoperative treatment for osteoarthritis of the hip and knee. To our knowledge, no peer-reviewed data exist to document the usage frequency of these injections nor to quantify the public interest in these injections. We sought to use Google Trends to provide a quantitative analysis of interest in hip and knee stem cell injections at the population level. METHODS: Google Trends search parameters were set to obtain query data from January 2010 through December 2017. 'Arthritis,' 'osteoarthritis,' 'stem cell,' 'injection,' 'knee,' and 'hip' were entered in various combinations to obtain the highest yield search volume. Trend analyses were performed. RESULTS: Six linear models were generated to show trends in the volume of searches for the United States and the World. Model fit was good, and regression analysis showed significant trends over time for all searches. Use of search terms increased significantly over time (all models P < .001). Adjusted R-square values ranged from 54.4% to 78.1%. All trends showed an upward trajectory for the entirety of the study time period. CONCLUSION: There has been a marked and statistically significant rise in search query volume related to stem cells and osteoarthritis of the hip and knee since 2010. Online interest in stem cell injections may suggest increased utilization of these procedures. Well-designed clinical studies are required to keep pace with the rising popularity and public interest in this intervention for hip and knee arthritis.

A Healthcare Improvement Intervention Combining Nucleic Acid Microarray Testing With Direct Physician Response for Management of Staphylococcus aureus Bacteremia.

Background: Nucleic acid microarray (NAM) testing for detection of Staphylococcus aureus bacteremia (SAB) and S. aureus resistance gene determinants can reduce time to targeted antibiotic administration. Evidence-based management of SAB includes bedside infectious diseases (ID) consultation. As a healthcare improvement initiative at our institution, with the goal of improving management and outcomes for subjects with SAB, we implemented NAM with a process for responding to positive NAM results by directly triggered, mandatory ID consultation. Methods: Preintervention, SAB was identified by traditional culture and results passively directed to antibiotic stewardship program (ASP) pharmacists. Postintervention, SAB in adult inpatients was identified by Verigene Gram-Positive Blood Culture test, results paged directly to ID fellow physicians, and consultation initiated immediately. In the new process, ASP assisted with management after the initial consultation. A single-center, retrospective, pre-/postintervention analysis was performed. Results: One hundred six preintervention and 120 postintervention subjects were assessed. Time to ID consultation after notification of a positive blood culture decreased 26.0 hours (95% confidence interval [CI], 45.1 to 7.1 hours, P < .001) postintervention compared with preintervention. Time to initiation of targeted antibiotic decreased by a mean of 21.2 hours (95% CI, 31.4 to 11.0 hours, P < .001) and time to targeted antibiotics for methicillin-sensitive S. aureus decreased by a mean of 40.7 hours (95% CI, 58.0 to 23.5 hours, P < .001). The intervention was associated with lower in-hospital (13.2% to 5.8%, P = .047) and 30-day (17.9% to 8.3%, P = .025) mortality. Conclusions: Compared with an ASP-directed response to traditionally detected SAB, an efficient physician response to NAM was associated with improved care and outcomes for SAB.

Certificate-of-Need State Laws and Total Knee Arthroplasty.

BACKGROUND: Many states in the United States have certificate-of-need (CON) programs designed to restrain health care costs and prevent overutilization of health care resources. The goal of this study was to characterize the associations between CON regulations and total knee arthroplasty (TKA) by comparing states with and without CON programs. METHODS: Publicly available data were used to classify states in to CON or non-CON categories. The 100% Medicare Standard Analytical Files from 2005 through 2014 were then used to compare primary TKA procedure volumes, charges, reimbursements, and distribution of procedures based on facility volumes between the groups. Adverse events such as infection and emergency room visits after TKA were also evaluated. RESULTS: Although CON status was associated with lower per capita utilization of TKA, the annual incidence of TKA appears to have increased over time more rapidly in states with CON laws compared with non-CON states (overall increase of 5.6% vs 2.3%, P < .01). When normalized to the Medicare population, the incidence of TKA increased 2.0% in CON states, whereas it actually decreased 7.2% in states without CON regulations (P = .011). Average reimbursement (and thus Medicare spend) was 5% to 10% lower in non-CON states at all time points (P < .0001). In non-CON states, relatively more TKAs appear to be performed in lower volume hospitals. Examination of adverse events rates did not reveal any strong associations between any adverse outcome and CON status. CONCLUSION: CON programs appear to have influenced the delivery of care for TKA. Although our data suggest that these laws are associated with lower per capita utilization of TKA and the use of higher-volume facilities, we were unable to detect any strong evidence that CON regulations have been associated with improved quality of care or have limited growth in the utilization of this procedure over time. Confounding population and geographic factors may influence these findings and further study is needed to determine whether or not these programs have served their purpose and should be retained.