Ethical Considerations of Declining Surgical Intervention: Balancing Patient Wishes with Fiduciary Responsibility.

ABSTRACT: Orthopaedic surgeons face increasing pressure to meet quality metrics due to regulatory changes and payment policies. Poor outcomes, including patient mortality, can result in financial penalties and negative ratings. Importantly, adverse outcomes often increase surgeon stress level and lead to job dissatisfaction and burnout. Despite optimization efforts, some orthopaedic patients remain at high risk for complications. In this article, we explore the ethical considerations when surgeons are presented with high-risk surgical candidates. We examine how the ethical tenets of patient interests, namely beneficence, nonmaleficence, autonomy, and justice, apply to such patients. We discuss external forces such as the malpractice environment, financial challenges in health-care delivery, and quality rankings. Informed consent and the challenges of communicating risks to patients are discussed, as well as the role of modifiable and nonmodifiable risk factors. Case examples with varied outcomes highlight the complexities of decision-making with high-risk patients and the potential role of palliative care. We provide recommendations for surgeons and care teams, including the importance of justifiable reasons for not operating, the utilization of institutional resources to help make care decisions, and the robust communication of risks to patients.

Rapid Adoption of Telemedicine Increases Opioid Prescribing in Orthopedic Surgery.

Background: The COVID-19 pandemic led to health care practitioners utilizing new technologies to deliver health care, including telemedicine. The purpose of this study was to examine the effect of rapidly proliferative use of video visits on opioid prescribing to orthopedic patients at a large academic health system that had existing procedure-specific opioid prescribing guidelines. Methods: This IRB-exempt study examined 651 opioid prescriptions written to patients who had video (visual and audio), telephone (audio only), or in-person encounters at our institution from March 1 to June 1, 2020 and compared them with 963 prescriptions written during the same months in 2019. Prescriptions were converted into daily milligram morphine equivalents (MMEs) to facilitate direct comparison. Chi-square testing was used to compare categorical data, whereas analysis of variance and Mann-Whitney tests were used to compare numerical data between groups. Statistical significance was set at <0.05. Results: Six hundred fifty-one of 1,614 prescriptions analyzed (40.3%) occurred during the pandemic. Patients prescribed opioids during video visits were prescribed 53.3 ± 37 MME, significantly higher than in-person (p = 0.002) or audio visits (p < 0.001) before or during the pandemic. Prepandemic, significantly higher MME were prescribed for in-person versus audio only visits (41.6 ± 89 vs. 30.2 ± 28 MME; p = 0.026); during the pandemic, there was no difference between these groups (p = 0.91). Significantly higher MME were prescribed by Nurse Practitioners and Physician Associates versus MD or DO prescribers for both time periods (51.3 ± 109 vs. 27.9 ± 42 MME; p < 0.001; 42.9 ± 70 vs. 28.2 ± 42 MME; p < 0.001). Conclusion: During crisis and with new technology, we should be vigilant about prescribing of opioid analgesics. Despite well-established protocols, patients received significantly higher MME through video than for other encounter types, including in-person encounters. In addition, significantly higher MME were prescribed by mid-level prescribers compared with DOs or MDs. Institutions should ensure these prescribers are involved during creation of opioid prescribing protocols after orthopedic surgery.

The Effect of Medicare's Bundled Payments for Care Initiative on Patient Risk Factors Prior to Total Knee Arthroplasty.

BACKGROUND: Medicare's Bundled Payments for Care Initiative (BPCI) is a risk-sharing alternative payment model. There is a concern that BPCI providers may avoid operating on obese patients and active smokers to reduce costs. We sought to understand if increased focus on these patient factors has led to a change in patient demographics in Medicare-insured patients undergoing total knee arthroplasty (TKA). METHODS: We retrospectively reviewed all patients who underwent TKA at an academic orthopedic specialty hospital between 1/1/13 and 8/31/19. Surgical date, insurance provider, BMI, and smoking status were collected. Patients were categorized as a current, former, or never smoker. Patients were categorized as obese if their BMI was >30 kg/m2, morbidly obese if their BMI was >40 kg/m2, and super obese if their BMI was >50 kg/m2. RESULTS: In total, 10,979 patients with complete insurance information were analyzed. There was no statistically significant change in the proportion of Medicare patients who were active smokers (4.34% in 2013, 4.85% in 2019, Pearson correlation coefficient = 0.6092, P = .146). The proportion of Medicare patients with BMI >30 kg/m2 increased over the study period (35.84% in 2013, 55.77% in 2019, Pearson correlation coefficient = 0.8505, P = .015). When looking at patients with BMI >40 kg/m2 and >50 kg/m2, there was no significant change. CONCLUSIONS: Despite concern that reimbursement payments could alter access to care for patients with certain risk factors, this study did not find a noticeable difference in the representation of patients with obesity and smoking status undergoing TKA following the installation of BPCI. LEVEL OF EVIDENCE: III, retrospective observational analysis.

Emergency Department Observation Versus Readmission Following total Joint Arthroplasty: Can We Avoid the Bundle Buster?

BACKGROUND: As the Center for Medicare and Medicaid (CMS) moves toward bundled payment plans for total joint arthroplasty (TJA), it becomes necessary to reduce factors that increase cost for an episode of care such as readmissions. The goal of this study is to evaluate the payment for observation stay versus readmission for patients who present to the emergency department. METHODS: A retrospective review from 2014-2019 was conducted identifying all Medicare patients who had a primary, elective TJA and visited the ED within 90 days postoperatively. If a readmission was one midnight or less or had an equivalent diagnosis to an observation stay patient, it was characterized as a readmission that could have qualified as an observation stay. Using our institution's average payment for Medicare readmissions and observations, actual and potential savings were calculated. RESULTS: Sixty-nine out of 523 (13.2%) patients were placed under observation, while 454 (86.8%) patients were readmitted. Eighty-six out of 523 (18.9%) patients qualified for observation status. There was an actual savings of 11.8% by placing patients on observation status and readmission rate was decreased by 13.2%. Savings could have increased by a total of 27.7% and readmissions decreased by a total of 29.6% if all patients who qualified had been placed on observation status. CONCLUSION: At our institution, the implementation of observation stay has led to a savings of 11.8% and a potential total savings of 27.7%. The rate of readmissions was decreased by 13.2% and had the potential to decrease by a total of 29.6%.

Opioid Prescribing Patterns in Orthopaedic Surgery Patients: the Effect of New York State Regulations and Institutional Initiatives.

BACKGROUND: The opioid epidemic in the United States is a public health crisis. As a result, regulatory agencies, including state governments, have enacted initiatives to decrease the use of opioids in the perioperative setting. The purpose of this study was to compare opioid utilization in orthopaedic surgery patients at discrete points after implementation of State regulatory and institution/physician-led initiatives to decrease opioid utilization in the perioperative period. METHODS: We reviewed the electronic medication orders for all patients who underwent orthopaedic surgery procedures between September 2015 and June 2018 at our urban academic medical center. The outcome measures were the number of patients who were prescribed opioid medications, duration of prescription (days), and average milligram morphine equivalents prescribed. Patients were divided into three time cohorts to assess the effect of the NY State (NYS) policy and institutional initiatives to decrease opioid utilization. RESULTS: A total of 20,483 patients met the inclusion criteria over all three time cohorts. After the initiation of the NYS 7-day supply legislation, there was a decrease in the average supply of opioids prescribed from 10.1 to 7.6 days and the average daily milligram morphine equivalent decreased from 67.9 to 56.7 mg (P < 0.0001). However, with the combination of physician education and surgeon-led institutional initiatives, the percentage of patients who were prescribed opioids decreased by over 10% (96% to 84%), with continued decrease in duration of prescription by 1.0 to 6.4 days (P < 0.0001). CONCLUSIONS: The addition of institution-led initiatives and education programs to previously established government-led prescription limits produced a substantial reduction in the amount of opioids prescribed to orthopaedic surgery patients in the perioperative period. Although mandatory limits set by the state government resulted in a decreased amount of opioid medications being prescribed per patient, it was only after the introduction of educational programs and institution- and physician-led programs that perioperative patient exposure to opioids decreased. LEVEL OF EVIDENCE: Level III.

Applying Systems Engineering to Increase Operating Room Efficiency.

Systems engineering is an interdisciplinary approach to creating, evaluating, and managing a complex process in order to increase reliability, cost-effectiveness, and quality. The operating room is a complex environment that requires human-human interaction, human-device interaction, planning, and coordination of scarce resources for the purpose of providing surgery to patients in a safe and efficient manner. The operating room is an important revenue generator, but it can also be responsible for unsustainable costs if not managed effectively. Reducing costs and increasing the efficiency of surgical cases is important for generating health care value. Efficiency efforts that aim for standardization of surgical protocols must be balanced by flexibility in the unpredictable operating room environment. This paper reviews systems engineering efforts to improve efficiency in the operating room including operating room scheduling, personnel factors, resource management, orthopedicspecific initiatives, and future innovations.

Trends in Pain Medication Prescriptions and Satisfaction Scores in Spine Surgery Patients at a Single Institution.

BACKGROUND: As the opioid crisis has gained national attention, there have been increasing efforts to decrease opioid usage. Simultaneously, patient satisfaction has been a crucial metric in the American health care system and has been closely linked to effective pain management in surgical patients. The purpose of this study was to examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients. METHODS: A total of 1729 patients undergoing spine surgery between June 25, 2017, and June 30, 2018, at a single institution by surgeons performing ≥20 surgeries per quarter, with medication data during hospitalization available, were assessed. Patients were evaluated for nonopioid pain medication prescription rates and morphine milligram equivalents (MME) of opioids used during hospitalization. Of the total cohort, 198 patients were evaluated for Press Ganey Satisfaction Survey responses. A χ2 test of independence was used to compare percentages, and 1-way analysis of variance was used to compare means across quarters. RESULTS: The mean total MME per patient hospitalization was 574.46, with no difference between quarters. However, mean MME per day decreased over time (P = .048), with highest mean 91.84 in Quarter 2 and lowest 77.50 in Quarter 4. Among all procedures, acetaminophen, nonsteroidal anti-inflammatory drugs, and steroid prescription rates increased, whereas benzodiazepine and γ-aminobutyric acid-analog prescriptions decreased. There were no significant differences between quarters for mean hospital ratings (P = .521) nor for responses to questions from the Press Ganey Satisfaction Survey regarding how often staff talk about pain (P = .164), how often staff talk about pain treatment (P = .595), or whether patients recommended the hospital (P = .096). There were also no differences between quarters for responses in all other patient satisfaction questions (P value range, .359-.988). CONCLUSIONS: Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without affecting overall satisfaction rates. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: The opioid epidemic has highlighted the need to reduce opioid usage in orthopedic spine surgery. This study reviews the trends for inpatient management of post-op pain in orthopedic spine surgery patients in relation to patient satisfaction. There was a significant increase in non-opioid analgesic pain medications, and a reduction in opioids during the study period. During this time, patient satisfaction as measured by Press-Ganey surveys did not show a decrease. This demonstrates that treatment of post-operative pain in orthopedic spine surgery patients can be managed with less opioids, more multimodal analgesia, and patient satisfaction will not be affected.

Outcomes of Same-Day Discharge After Total Hip Arthroplasty in the Medicare Population.

BACKGROUND: There is an increasing utilization of same-day discharge total hip arthroplasty (SDD THA). As the Center for Medicare and Medicaid Services considers removing THA from the inpatient-only list, there is likely to be a significant increase in the number of Medicare patients undergoing SDD THA. Thus, there is a need to report on outcomes of SDD THA in this population. METHODS: A retrospective review was performed on 850 consecutive SDD THA patients including 161 Medicare patients. We compared failure to launch, complication, emergency department visit, and 90-day readmission rates between the Medicare and non-Medicare cohorts. RESULTS: The Medicare group was older and had less variability in their admission diagnosis. There was no significant difference in failure to launch, complication, emergency department visit, or 90-day readmission rates between Medicare and non-Medicare groups. CONCLUSION: The benefits of SDD THA can be safely extended to the carefully indicated and motivated Medicare patient.

Ethics of Opioid Prescriber Regulations: Physicians, Patients, and Pain.

BACKGROUND: Opioid addiction affects patients of every race, sex, and socioeconomic status. Overprescribing is a known cause of the opioid crisis. Various agencies have implemented requirements and programs to combat practitioner overprescribing; however, there can be adverse ethical consequences when regulations are used to influence physician behavior. We aimed to explore the ethical aspects of some of these interventions. METHODS: We reviewed various interventions for opioid prescribing through the lens of ethical inquiry. Specifically, we evaluated (1) requirements for educational programs for prescribers and patients, (2) prescription monitoring programs, (3) prescription limits, (4) development of condition-specific pain management guidelines, (5) increased utilization of naloxone, and (6) opioid disposal programs. We also evaluated patient satisfaction survey questions relating to pain. RESULTS: The present analysis demonstrated that the following regulatory interventions are ethically sound: requirements for educational programs for prescribers and patients, robust prescription monitoring programs that cross state lines, increased prescribing of naloxone for at-risk patients, development of condition-specific pain management guidelines, improvement of opioid disposal programs, and elimination of pain-control questions from patient satisfaction surveys. However, implementation of strict prescribing limits without accommodation for procedure and patient characteristics may have negative ethical consequences. CONCLUSIONS: Although the importance of addressing the current opioid crisis cannot be understated, as surgeons, we must examine ethical implications of any new regulations that affect musculoskeletal patient care.

The Cost Effectiveness of Birth-Cohort Hepatitis C Screening During Pre-Admission Testing for Elective Procedures at a Single Specialty Orthopedic Hospital.

In 2012, the Centers for Disease Control and Prevention issued a recommendation for hepatitis C screening of adults born between 1945-1965. Our institution incorporated birthcohort screening into its pre-admission testing program for elective orthopedic procedures on February 3, 2015. The goal of this study was to report the results and costs of pre-admission birth-cohort hepatitis C screening at our institution from February 3, 2015, to January 27, 2017. A total of 11,659 elective inpatient procedures were scheduled during this time and 97.8% of eligible patients were screened. Nine patients with active infection were identified, and four were successfully treated. Costs were calculated using time-driven activity-based costing. The total screening cost per successfully treated patient was $36,930.02. Since patients were not routinely screened at our institution before this intervention, our 97.8% screening capture rate demonstrates that pre-admission testing for elective procedures is a novel, yet effective and underutilized way, to engage "baby boomers" in screening.

Are HCAHPS Scores Higher for Private vs Double-Occupancy Inpatient Rooms in Total Joint Arthroplasty Patients?

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.

Total Joint Arthroplasty in Ambulatory Surgery Centers: Analysis of Disqualifying Conditions and the Frequency at Which They Occur.

BACKGROUND: The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible. METHODS: We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities. RESULTS: Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m2 (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%). CONCLUSION: A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.

Hip Arthroplasty for Fracture vs Elective Care: One Bundle Does Not Fit All.

BACKGROUND: To quantify how baseline differences in patients undergoing hip arthroplasty for fracture vs elective care potentially lead to significant differences in immediate health care outcomes and whether these differences affect feasibility of current bundled payment models. METHODS: New York Statewide Planning and Research Cooperative System database for the years 2000-2014. RESULTS: A total of 76,654 patients underwent total hip arthroplasty or hemiarthroplasty between 2010 and 2014; 82.8% of the sample was for elective care and 17.2% for fracture-related etiology. Fracture patients were significantly older, more likely to be female, Caucasian, reimbursed by Medicare, and receive general anesthesia. Comorbidity burden and postoperative complications were significantly higher in the fracture group, and hospital charges were significantly greater for fracture patients as compared with those of the elective cohort. CONCLUSION: Patients undergoing hip arthroplasty for fracture care are significantly older and have more medical comorbidities than patients treated on an elective basis, leading to more in-hospital complications, greater length of stay, increased hospital costs, and significantly more hospital readmissions. The present bundled payment system, even with the recent modification, still unfairly penalizes hospitals that manage fracture patients and has the potential to incentivize hospitals to defer providing definitive surgical management for these patients. Future amendments to the bundled payment system should consider further separating hip arthroplasty patients based on etiology and comorbidities, allowing for a more accurate reflection of these distinct patient groups.

Joint Replacement Volume Positively Correlates With Improved Hospital Performance on Centers for Medicare and Medicaid Services Quality Metrics.

BACKGROUND: The Center for Medicare and Medicaid Services (CMS) is transitioning Medicare from a fee-for-service program into a value-based pay-for-performance program. In order to accomplish this goal, CMS initiated 3 programs that attempt to define quality and seek to reward high-performing hospitals and penalize poor-performing hospitals. These programs include (1) penalties for hospital-acquired conditions (HACs), (2) penalties for excess readmissions for certain conditions, and (3) performance on value-based purchasing (VBP). The objective of this study was to determine whether high-volume total joint hospitals perform better in these programs than their lower-volume counterparts. METHODS: We analyzed data from the New York Statewide Planning and Research Cooperative System database on total New York State hospital discharges from 2013 to 2015 for total knee and total hip arthroplasty. This was compared to data from Hospital Compare on HAC's, excess readmissions, and VBP. From these databases, we identified 123 hospitals in New York, which participated in all 3 Medicare pay-for-performance programs and performed total joint replacements. RESULTS: Over the 3-year period spanning 2013-2015, hospitals in New York State performed an average of 1136.59 total joint replacement surgeries and achieved a mean readmission penalty of 0.005909. The correlation coefficient between surgery volume and combined performance score was 0.277. Of these correlations, surgery volume and VBP performance, and surgery volume and combined performance showed statistical significance (P < .01). CONCLUSION: Our study demonstrates that there is a positive association between joint replacement volumes and overall hospital quality, as well as joint replacement volumes and VBP performance, specifically. These findings are consistent with previously reported associations between patient outcomes and procedure volumes. However, a relationship between joint replacement volume and HAC scores or readmission penalties could not be demonstrated.

End Tidal Carbon Dioxide as a Screening Tool for Computed Tomography Angiogram in Postoperative Orthopaedic Patients Suspected of Pulmonary Embolism.

BACKGROUND: Computed tomography pulmonary angiography (CTA) is the gold standard for diagnosing pulmonary embolism (PE) but involves radiation and iodinated contrast exposure. Of orthopedic patients evaluated for PE, a minority have a positive CTA study. Herein, we evaluate end tidal carbon dioxide (ETCO2) as a method to identify patients at low risk for PE and may not require a CTA. We hypothesize that ETCO2 will be useful for predicting the absence of PE in postoperative orthopedic patients. METHODS: In this prospective study, all patients older than 18 years who were admitted for orthopedic surgery and who had a CTA performed for PE were eligible. These patients underwent an ETCO2 measurement. Patients were determined to have PE if they had a positive PE-protocol CT. RESULTS: Between May 2014 and April 2015, 121 patients met the inclusion criteria for the study. Of these patients, 84 had a negative CTA examination, 25 had a positive examination, and 12 had a nondiagnostic examination. We found a statistically significant difference (P = .03) when comparing the average ETCO2 values for the positive and negative CTA groups. An ETCO2 cutoff value of 43 mm Hg was 100% sensitive with a negative predictive value of 100% for absence of PE on CTA. CONCLUSION: This study demonstrates a significant difference in ETCO2 measurements between postoperative orthopedic patients with and without CTA-detected PE. A cutoff value of >43 mm Hg may be useful in excluding patients from undergoing CTA.

The Relationship Between Hospital Payer Mix and Volume Growth in Total Joint Arthroplasty: A 12-Year Analysis.

BACKGROUND: Hospital reimbursement for Medicare/Medicaid/self-pay patients has not kept pace with rising expenses, and even well run efficient organizations struggle to maintain a positive margin on these cases. Therefore, hospitals rely on commercially insured patients to remain economically viable. However, hospitals located in areas with a high Medicare/Medicaid/uninsured population cannot depend on a favorable payer mix for financial sustainability. METHODS: Using the Statewide Planning and Research Cooperative System database, total joint arthroplasties (TJAs) in New York from 2000 to 2012 were identified. Hospitals were divided into quartiles by volume, with quartile 1 representing the lowest volume hospitals. TJA cases were stratified by primary payer type, and the percentage of each primary payer type was calculated and compared among quartiles. RESULTS: The highest number of hospitals performing TJAs was 207 in 2000, and the least number of hospitals was in 2012, with only 178 hospitals performing TJA. Despite the decrease in the number of hospitals, the total number of joint arthroplasties increased from 33,036 in 2000 to 62,104 in 2012. CONCLUSIONS: Our study demonstrates that higher volume hospitals tended to have a more favorable payer mix (less Medicare/Medicaid/self-pay patients). This inequity widened over the 12-year study period. This trend has ethical implications for lower socioeconomic status patients as high-volume centers tend to have superior outcomes compared with low-volume centers. In addition, the lower volume high Medicare/Medicaid/self-pay hospitals are more susceptible to the Center for Medicare and Medicaid Services quality penalties making their economic viability even more tenuous potentially leading to access of care problems for these patients.

Risk Factors for Postoperative Venous Thromboembolism in Orthopaedic Spine Surgery, Hip Arthroplasty, and Knee Arthroplasty Patients.

BACKGROUND: Orthopaedic surgery is a major risk factor for venous thromboembolism (VTE) manifesting as deep vein thrombosis (DVT) or pulmonary embolism (PE). Various patient characteristics alter the likelihood of a postoperative VTE, and there is substantial ambiguity in current VTE prophylaxis guidelines. PURPOSE: To determine if particular patient characteristics are risk factors for VTE following major orthopaedic surgery. METHODS: Data was reviewed from 201 patients presenting with either a PE or DVT following spine surgery or joint replacement from October 2009 through June 2013. The following characteristics were reviewed for each patient: VTE event date, surgery date and type, comorbidities and pre-existing conditions, calculated comorbidity level, body mass index, prophylaxis type, time to initiation of chemoprophylaxis, time to epidural removal, and VTE event type. The control patients were randomly selected from a group of 13,782 patients during the same period. RESULTS: A history of VTE (p < 0.0001), Factor V Leiden disorder (p = 0.04) and the use of general anesthesia (p =0.05) were significant risk factors for postoperative VTE. The frequency of VTE decreased following hip and knee arthroplasty during the study period and remained constant for spine surgery. DVTs occurred 14.2 days later than PEs (p < 0.0001). Over 90% of PEs and 33.3% to 75% of DVTs were diagnosed in the first week following surgery. CONCLUSIONS: A prior history of VTE, Factor V Leiden disorder and general anesthesia increases the risk of VTE postoperatively. The probability of PE beyond the second postoperative week is low.

Does Risk for Malnutrition in Patients Presenting With Fractures Predict Lower Quality Measures?

INTRODUCTION: The purpose of this study was to determine if nutritional screening could be used as a predictor for the development of complications and hospital readmissions. METHODS: A variation of the Malnutrition Universal Screening Tool (MUST) score was collected for all inpatients with orthopaedic trauma on admission to our hospital from 2009 to 2011. We retrospectively compared each patient's MUST score with the subsequent development of infection, venous thromboembolism, respiratory failure, ulceration, or readmission. Finally, a chart review was performed to collect comorbidity data and evaluate Charlson comorbidity indexes to estimate the overall health of each patient with an available MUST. RESULTS: Of the 796 consecutive patients in our total cohort, 57.7% (n = 459) were of normal nutritional status and 42.3% (n = 337) exhibited at least 1 sign of malnutrition. In patients with normal nutrition, 2.8% developed at least one of the specified complications, and we observed a complication-to-patient ratio of 0.033. In patients with signs of malnutrition, 8.0% developed at least 1 complication with a complication-to-patient ratio of 0.101. This difference was significant (P = 0.001). Multivariate regression analysis demonstrated that each additional point in a patient's nutrition score corresponded to a 49.5% increase in the odds of developing a complication when controlling for other factors (odds ratio = 1.495, confidence interval = 1.120-1.997, P = 0.006). Charlson comorbidity indexes were not significantly associated with total complications when MUST scores used were a covariant. DISCUSSION AND CONCLUSIONS: Patients treated for fractures and dislocations with any sign of malnutrition according to the MUST score were more than twice as likely to acquire some combination of infection, venous thromboembolism, respiratory failure, or other reason for readmission than those of normal nutritional status. Increasing levels of malnourishment corresponded with increasing risk for developing complications, whereas these complications were not necessarily associated with higher comorbidity. An assessment of a fracture patient's nutritional status should be considered a factor in evaluating risks related to fracture care. The MUST score is a predictive tool. These data have important implications for hospitals whose fiscal reimbursement is dependent on the maintenance of defined quality measures. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Using "near misses" analysis to prevent wrong-site surgery.

UNLABELLED: The purpose of our pre-post intervention study was to reduce the number of near-miss events pertaining to wrong-site surgery, including incorrectly sided surgical bookings and incorrectly performed preoperative time-out procedures. Pre- and postintervention, incorrectly booked cases, and improperly performed presurgical time-out procedures were recorded. We then educated each surgeon and their staff regarding the importance of and proper way to perform these tasks. Subsequently, the monthly percentage of incorrectly booked surgical procedures and improperly performed time-outs were significantly decreased. INTRODUCTION: In 2004, the Joint Commission published comprehensive guidelines to prevent wrong-site surgery. Seven years have passed, and the incidence has not declined. The Joint Commission estimates that in the United States, wrong-site procedures including surgeries occur at least 40 times a week. "Near misses" are events that could have harmed a patient, but did not due to chance or mitigation. Improperly performed time-out procedures and inaccurate surgical bookings are considered near misses and could ultimately lead to "never events," such as wrong-site surgery. Near-miss analysis is a highly effective method of preventing rare, "never events." We hypothesize that proper education of surgeons and staff will be effective in reducing the number of near misses. METHODS: All cases analyzed were performed at an academic, orthopedic surgery specialty institution. From August 2010 to May 2011, near misses were identified and stored in Patient Safety Net (PSN), an electronic database. We tracked these cases and educated each offending attending physician and his or her staff about the importance of accurate surgical bookings. Additionally, we began an observational program to carefully review presurgical time-out procedures as they occurred. We tracked the percentage of these improperly performed time-outs and counseled offenders (attending surgeon, or any member of the operating room staff who made the error) regarding the deficiencies that caused the time-out to be ineffective. The number of near misses that occurred before and after the interventions were recorded and analyzed. RESULTS: Of the 12,215 cases included in this study, 6,126 cases formulated the "pre-education" cohort, while a total of 6,089 cases formulated the "post-education" cohort. In the first four months of the study, the monthly rate of incorrectly booked cases was 0.75%. Since the intervention, the rate decreased to 0.41% (p = .0139). The percentage of improperly performed time-out procedures decreased from 18.7% to 5.9% after the educational interventions were performed (p < .0001). CONCLUSION: A program designed to educate physicians to the importance of decreasing near misses for wrong-site surgery is effective. When analyzing the literature, it is clear that the reduction in near misses observed in this study decreases the likelihood of a wrong-site surgery.

Correlation between physician specific discharge costs, LOS, and 30-day readmission rates: an analysis of 1,831 cases.

There is currently wide variation in the use and cost of post acute care following total joint arthroplasty. Additionally the optimum setting to which patients should be discharged after surgery is controversial. Discharge patterns following joint replacement vary widely between physicians at our institution, however, only weak correlations were found between the cost of discharge and length of stay or readmission rates. The inter-physician variance in discharge cost did not correlate to a difference in quality, as measured by length of stay and readmission rates, but does imply there is significant opportunity to modify physician discharge practices without impacting patient outcomes and the quality of care.