Hip fracture characteristics and outcomes during COVID-19: a large retrospective national database review.

BACKGROUND: The COVID-19 pandemic has impacted healthcare in various vulnerable patient subpopulations. However, data are lacking on the impact of COVID-19 on hip fractures, seen mainly in older patients. Using national claims data, we aimed to describe the epidemiology during the first COVID-19 wave in the USA. METHODS: We compared patients admitted for hip fractures during March and April of 2020 with those admitted in 2019 in terms of patient and healthcare characteristics, COVID-19 diagnosis, and outcomes. An additional comparison was made between COVID-19-positive and -negative patients. Outcomes included length of hospital stay (LOS), admission to an ICU, ICU LOS, use of mechanical ventilation, 30-day readmission, discharge disposition, and a composite variable of postoperative complications. RESULTS: Overall, 16 068 hip fractures were observed in 2019 compared with 7498 in 2020. Patients with hip fractures in 2020 (compared with 2019) experienced earlier hospital discharge and were less likely to be admitted to ICU, but more likely to be admitted to home. Amongst 83 patients with hip fractures with concomitant COVID-19 diagnosis, we specifically observed more non-surgical treatments, almost doubled LOS, a more than 10-fold increased mortality rate, and higher complication rates compared with COVID-19-negative patients. CONCLUSIONS: The COVID-19 pandemic significantly impacted not only volume of hip fractures, but also patterns in care and outcomes. These results may inform policymakers in future outbreaks and how this may affect vulnerable patient populations, such as those experiencing a hip fracture.

Association between sex and perioperative opioid prescribing for total joint arthroplasty: a retrospective population-based study.

BACKGROUND: Scarce data exist on differential opioid prescribing between men and women in the pre-, peri-, and postoperative phases of care among patients undergoing total hip/knee arthroplasty (THA/TKA). METHODS: In this retrospective population-based study, Truven Health MarketScan claims data were used to establish differences between men and women in (1) opioid prescribing in the year before THA/TKA surgery, (2) the amount of opioids prescribed at discharge, and (3) chronic opioid prescribing (3-12 months after surgery). Multivariable regression models measured odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS: Among 29 038 THAs (42% men) and 48 523 TKAs (52% men) men (compared with women) were less likely to receive an opioid prescription in the year before surgery (54% vs 60%, and 54% vs 60% for THA and TKA, respectively); P<0.001. However, in multivariable analyses male sex was associated with higher total opioid dosages prescribed at discharge after THA (OR=1.04; 95% CI 1.03, 1.06) and TKA (OR=1.05; 95% CI 1.04, 1.06); both P<0.001. Chronic opioid prescribing was found in 10% of the cohort (THA: n=2333; TKA: n=5365). Here, men demonstrated lower odds of persistent opioid prescribing specifically after THA (OR=0.90; 95% CI 0.82, 0.99) but not TKA (OR=0.96; 95% CI 0.90, 1.02); P=0.026 and P=0.207, respectively. CONCLUSIONS: We found sex-based differences in opioid prescribing across all phases of care for THA/TKA. The results highlight temporal opportunities for targeted interventions to improve outcomes after total joint arthroplasty, particularly for women, and to decrease chronic opioid prescribing.

Persistent opioid use after surgical treatment of paediatric fracture.

BACKGROUND: The opioid epidemic is one of the most pressing public health crises in the USA. With fractures being amongst the most common reasons for a child to require surgical intervention and receive post-surgical pain management, characterisation of opioid prescription patterns and risk factors is critical. We hypothesised that the numbers of paediatric patients receiving opioids, or who developed persistent opioid use, are significant, and a number of risk factors for persistent opioid use could be identified. METHODS: We conducted a retrospective population-based cohort study. National claims data from the Truven Health Analytics® MarketScan database were used to (i) characterise opioid prescription patterns and (ii) describe the epidemiology and risk factors for single use and persistent use of opioids amongst paediatric patients who underwent surgical intervention for fracture treatment. RESULTS: Amongst 303 335 patients, 21.5% received at least one opioid prescription within 6 months after surgery, and 1671 (0.6%) developed persistent opioid use. Risk factors for persistent opioid use include older age; female sex; lower extremity trauma; surgeries involving the spine, rib cage, or head; closed fracture treatment; earlier surgery years; previous use of opioid; and higher comorbidity burden. CONCLUSIONS: Amongst a cohort of paediatric patients who underwent surgical fracture treatment, 21.5% filled at least one opioid prescription, and 0.6% (N=1671) filled at least one more opioid prescription between 3 and 6 months after surgery. Understanding risk factors related to persistent opioid use can help clinicians devise strategies to counter the development of persistent opioid use for paediatric patients.

Differential Perioperative Outcomes in Patients With Obstructive Sleep Apnea, Obesity, or a Combination of Both Undergoing Open Colectomy: A Population-Based Observational Study.

BACKGROUND: An increasing body of evidence demonstrates an association between obstructive sleep apnea (OSA) and adverse perioperative outcomes. However, large-scale data on open colectomies are lacking. Moreover, the interaction of obesity with OSA is unknown. This study examines the impact of OSA, obesity, or a combination of both, on perioperative complications in patients undergoing open colectomy. We hypothesized that while both obesity and OSA individually increase the likelihood for perioperative complications, the overlap of the 2 conditions is associated with the highest risk. METHODS: Patients undergoing open colectomies were identified using the national Premier Healthcare claims-based Database (2006-2016; n = 340,047). Multilevel multivariable models and relative excess risk due to interaction (RERI) analysis quantified the impact of OSA, obesity, or both on length and cost of hospitalization, respiratory and cardiac complications, intensive care unit (ICU) admission, mechanical ventilation, and inhospital mortality. RESULTS: Nine thousand twenty-eight (2.7%) patients had both OSA and obesity diagnoses; 10,137 (3.0%) had OSA without obesity; and 33,692 (9.9%) had obesity without OSA. Although there were overlapping confidence intervals in the binary outcomes, the risk increase was found highest for OSA with obesity, intermediate for obesity without OSA, and lowest for OSA without obesity. The strongest effects were seen for respiratory complications: odds ratio (OR), 2.41 (2.28-2.56), OR, 1.40 (1.31-1.49), and OR, 1.50 (1.45-1.56), for OSA with obesity, OSA without obesity, and obesity without OSA, respectively (all P < .0001). RERI analysis revealed a supraadditive effect of 0.51 (95% confidence interval [CI], 0.34-0.68) for respiratory complications, 0.11 (-0.04 to 0.26) for cardiac complications, 0.30 (0.14-0.45) for ICU utilization, 0.34 (0.21-0.47) for mechanical ventilation utilization, and 0.26 (0.15-0.37) for mortality in patients with both OSA and obesity, compared to the sum of the conditions' individual risks. Inhospital mortality was significantly higher in patients with both OSA and obesity (OR [CI], 1.21 [1.07-1.38]) but not in the other groups. CONCLUSIONS: Both OSA and obesity are individually associated with adverse perioperative outcomes, with a supraadditive effect if both OSA and obesity are present. Interventions, screening, and perioperative precautionary measures should be tailored to the respective risk profile. Moreover, both conditions appear to be underreported compared to the general population, highlighting the need for stringent perioperative screening, documentation, and reporting.

Trends in Comorbidities and Complications Among Patients Undergoing Hip Fracture Repair.

BACKGROUND: Hip fracture patients represent various perioperative challenges related to their significant comorbidity burden and the high incidence of morbidity and mortality. As population trend data remain rare, we aimed to investigate nationwide trends in the United States in patient demographics and outcomes in patients after hip fracture repair surgery. METHODS: After Institutional Review Board (IRB) approval (IRB#2012-050), data covering hip fracture repair surgeries were extracted from the Premier Healthcare Database (2006-2016). Patient demographics, comorbidities, and complications, as well as anesthesia and surgical details, were analyzed over time. Cochran-Armitage trend tests and simple linear regression assessed significance of (linear) trends. RESULTS: Among N = 507,274 hip fracture cases, we observed significant increases in the incidence in preexisting comorbid conditions, particularly the proportion of patients with >3 comorbid conditions (33.9% to 43.4%, respectively; P < .0001). The greatest increase for individual comorbidities was seen for sleep apnea, drug abuse, weight loss, and obesity. Regarding complications, increased rates over time were seen for acute renal failure (from 6.9 to 11.1 per 1000 inpatient days; P < .0001), while significant decreasing trends for mortality, pneumonia, hemorrhage/hematoma, and acute myocardial infarction were recorded. In addition, decreasing trends were observed for the use of neuraxial anesthesia either used as sole anesthetic or combined with general anesthesia (7.3% to 3.6% and 6.3% to 3.4%, respectively; P < .0001). Significantly more patients (31.9% vs 41.3%; P < .0001) were operated on in small rather than medium- and large-sized hospitals. CONCLUSIONS: From 2006 to 2016, the overall comorbidity burden increased among patients undergoing hip fracture repair surgery. Throughout this same time period, incidence of postoperative complications either remained constant or declined with the only significant increase observed in acute renal failure. Moreover, use of regional anesthesia decreased over time. This more comorbid patient population represents an increasing burden on the health care system; however, existing preventative measures appear to be effective in minimizing complication rates. Although, given the proposed benefits of regional anesthesia, decreased utilization may be of concern.

Venous thromboembolism and prophylaxis therapy after elective spine surgery: a population-based study.

PURPOSE: Currently, there is no generalized consensus regarding perioperative prophylaxis of venous thromboembolism (VTE) in patients undergoing spine surgery. In the absence of large-scale studies, we aimed to use national data to study the association between anticoagulant prophylaxis and VTE in spine surgical patients. Our secondary outcomes were hematoma and blood transfusion. METHODS: We included anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) cases from 2006 to 2016 recorded in the Premier Healthcare database. Anticoagulant prophylaxis was categorized into aspirin, regular heparin, and low molecular weight heparin given on the day of surgery. Mixed-effects models measured the association between anticoagulation categories and outcomes. Cohorts were adjusted to reduce the risk of "confounding by indication" and to distinguish between prophylactic and therapeutic use of anticoagulants. We report odds ratios (OR) and Bonferroni-corrected confidence intervals (CI). RESULTS: Among 83,839 individuals undergoing ACDF and PLF, 0.45% (n = 374) had a hematoma, 8.1% (n = 6,769) received a blood transfusion, and 0.13% (n = 113) experienced VTE. After adjustment for relevant covariates, prophylactic aspirin (OR, 1.48; CI, 1.17 to 1.86) and regular heparin (OR, 2.01; CI, 1.81 to 2.24) were associated with increased odds of blood transfusion. No detectable differences in the odds of hematoma or VTE were observed for any anticoagulant. CONCLUSION: Although low molecular weight heparin was used much less frequently than regular heparin, it was associated with a lower incidence of transfusion compared with aspirin and regular heparin. All three anticoagulants were associated with similar incidence of VTE and hematoma. Varying subgroup-specific VTE risks may further inform future studies to identify patients expected to benefit the most from chemical thromboprophylaxis.

RéSUMé: OBJECTIF: À l'heure actuelle, il n'existe pas de consensus concernant la prophylaxie périopératoire en cas de thromboembolie veineuse (TEV) pour les patients subissant une chirurgie du rachis. En l'absence d'études de grande envergure, nous avons cherché à utiliser des données nationales afin d'étudier l'association entre l'anticoagulothérapie et la TEV chez les patients de chirurgie du rachis. Nos critères d'évaluation secondaires étaient la présence d'hématome et les transfusions sanguines. MéTHODE: Nous avons inclus les chirurgies de discectomie cervicale antérieure avec fusion (DCAF) et de fusion lombaire postérieure (FLP) réalisées entre 2006 et 2016 et enregistrées dans la base de données Premier Healthcare. L'anticoagulothérapie a été catégorisée en aspirine, héparine normale, et héparine de bas poids moléculaire, donnée le jour de la chirurgie. Les modèles à effets mixtes ont mesuré l'association entre les catégories d'anticoagulation et les critères d'évaluation. Les cohortes ont été ajustées afin de réduire le risque de « confusion par indication ¼ et de distinguer une utilisation prophylactique d'une utilisation thérapeutique des anticoagulants. Nous rapportons les rapports de cotes (RC) et les intervalles de confiance (IC) corrigés par Bonferroni. RéSULTATS: Parmi les 83 839 personnes ayant subi une DCAF ou une FLP, 0,45 % (n = 374) ont développé un hématome, 8,1 % (n = 6769) ont reçu une transfusion sanguine et 0,13 % (n = 113) ont souffert d'une TEV. Après ajustement pour tenir compte des covariables pertinentes, l'aspirine prophylactique (RC, 1,48; IC, 1,17 à 1,86) et l'héparine normale (RC, 2,01; IC, 1,81 à 2,24) ont été associées à des probabilités accrues de transfusion sanguine. Aucune différence détectable dans les risques d'hématome ou de TEV n'a été observée, indépendamment de l'anticoagulant utilisé. CONCLUSION: Bien que l'héparine de bas poids moléculaire ait été utilisée bien moins fréquemment que l'héparine normale, elle était associée à une incidence plus faible de transfusion par rapport à l'aspirine et à l'héparine normale. Les trois anticoagulants ont été associés à une incidence comparable de TEV et d'hématome. Les variations en matière de risque de TEV spécifiques aux sous-groupes pourraient orienter les études futures afin de tenter d'identifier les patients qui pourraient bénéficier le plus d'une thromboprophylaxie pharmaceutique.

Tranexamic Acid Administration is Associated With a Decreased Odds of Prosthetic Joint Infection Following Primary Total Hip and Primary Total Knee Arthroplasty: A National Database Analysis.

BACKGROUND: Tranexamic acid (TXA) for the reduction of blood loss in orthopedic surgery is coming into greater adoption. Because TXA administration lowers the incidence of blood transfusion and of hematoma formation, risk factors for infection, we asked whether TXA use might be associated with a lower incidence of periprosthetic joint infection (PJI) following orthopedic surgery. METHODS: We queried the Premier Healthcare database for ICD-9 codes corresponding to elective inpatient primary total hip replacement (THR) or total knee replacement (TKR) from 2012 to 2016, TXA administration on the day of surgery, and PJI during the hospital stay or within 90 days. We performed a multilevel multivariable logistic regression (SAS version 9.4. SAS Institute, Cary, NC) to determine if TXA administration or other covariates were a significant predictor of infection. RESULTS: Among 914,990 total joint arthroplasty patients, 46.0% received TXA on the day of surgery. 0.13% developed PJI within 90 days. After adjusting for patient and hospital-related covariates, TXA use was associated with significantly lower odds of PJI within 90 days of surgery (OR 0.49 [0.69, 0.91]). CONCLUSION: Administration of TXA on the day of surgery in total knee and total hip arthroplasty was associated with a statistically significant decreased odds of PJI in the first 90 days. We therefore conclude that TXA might play an important role in our attempts to decrease PJI after joint arthroplasty. The exact mechanisms and ideal dosage by which TXA can contribute to such a reduction need further study.

Enhanced recovery after surgery components and perioperative outcomes: a nationwide observational study.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been shown to benefit recovery after several operations. However, large-scale data on the association between the level of ERAS use and perioperative complications are scarce, particularly in surgeries with increasing ERAS uptake, including total hip (THA) and knee arthroplasty (TKA). Using US national data, we examined the relationship between the number of ERAS components implemented ('level') and perioperative outcomes. METHODS: After ethics approval, we included 1 540 462 elective THA/TKA procedures (2006-2016, as recorded in the Premier Healthcare claims database) in this retrospective cohort study. Main outcomes were any complication, cardiopulmonary complications, mortality, blood transfusions, and length of stay. Eight commonly used ERAS components were included. Mixed-effects models measured associations between ERAS level and outcomes, with odds ratios (OR) and confidence intervals (CI) reported. RESULTS: ERAS use increased over time; overall, 21.6% (n=324 437), 62.7% (n=965 953), and 18.0% (n=250 072) of cases were classified as 'High', 'Medium', or 'Low' ERAS. 'High ERAS', 'Medium ERAS', and 'Low ERAS' level of use were defined as such if they received either >6, 5-6, or <5 ERAS components, respectively. After adjustment for relevant covariates, higher levels of ERAS use were associated with incremental reductions in 'any complication': 'Medium' vs 'Low' (OR=0.84; CI, 0.82-0.86) and 'High' vs 'Low' (OR=0.71; CI, 0.68-0.74). Similar patterns were found for the other study outcomes. Individual ERAS components with the strongest effect estimates were early physical therapy, avoidance of a urinary catheter, and tranexamic acid administration. CONCLUSIONS: ERAS components were used more frequently over time, and the level of utilisation was independently associated with incrementally improved complication odds and reduced length of stay during the primary admission. Possible indication bias limits the certainty of these findings.

Trends and Outcomes in Pediatric Patients Undergoing Scoliosis Repair: A Population-Based Study.

BACKGROUND: Although surgery represents the only definitive treatment for congenital scoliosis, comprehensive information regarding trends in perioperative complications, particularly in the pediatric setting, is lacking. We sought to identify trends in and factors associated with perioperative complications following pediatric scoliosis surgery. METHODS: In this retrospective cohort study, patients below the age of 21 years undergoing a scoliosis repair procedure were identified from the Premier Healthcare database (2006-2016). The primary outcomes of interest were any complication, cardiopulmonary complications, blood transfusions, intensive care unit (ICU) admission, length of stay (LOS), and cost of hospitalization. Trends in these outcomes over time were analyzed. Multivariable logistic regression models were run to identify factors associated with each of the perioperative outcomes. RESULTS: In the full cohort of 9351 scoliosis patients, 17% experienced any complication, 12% of which were cardiopulmonary in nature, 42% required blood transfusions, and 62% were admitted to the ICU. Median LOS was 5 days (interquartile range [IQR], 4-6) and median cost was $56,375 (IQR, $40,053-$76,311). Annual incidence of complications and blood transfusions as well as LOS and cost decreased significantly throughout the study period. The most consistently observed factors associated with complications were younger age, high comorbidity burden, low institutional case volume, and hospital teaching status. CONCLUSIONS: Although the incidence of the studied adverse outcomes in scoliosis surgery has decreased over time, this study shows it remains relatively high (17%). The associations demonstrated help clarify factors associated with complications and may be useful in guiding interventions to improve outcomes.

Risk factors for reintubation after anterior cervical discectomy and fusion surgery: evaluation of three observational data sets.

PURPOSE: Postoperative loss of airway requiring reintubation is a rare but potentially catastrophic complication following anterior cervical discectomy and fusion (ACDF). We sought to identify risk factors asscociated with reintubation within one day following ACDF. Attention was focused on patient demographics, comorbidities, and factors potentially linked to soft tissue swelling and hematoma formation that could compromise the upper airway. METHODS: We performed a retrospective cohort study of patients who underwent ACDF procedures at a high-volume institution from 2005 to 2014 (n = 3,041), participating hospitals in the National Surgical Quality Improvement Program (NSQIP) (n = 47,425), and Premier Healthcare (n = 233,633) databases from 2006 to 2016. Separate multivariable logistic regression models using the NSQIP and Premier samples were used to identify risk factors for reintubation within one day of ACDF. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Incidence of reintubation within one day of ACDF was 0.19% in the institutional database and 0.21% in NSQIP and Premier databases. Risk factors for reintubation included older age, male sex, high comorbidity burden, procedures performed at large hospitals, non-elective procedures, Medicaid insurance, and use of heparin or more than one anticoagulant. Intravenous or oral steroid use (OR, 0.45; 95% CI, 0.36 to 0.56; P < 0.001) and delayed extubation (OR, 0.28 95% CI, 0.16 to 0.49; P < 0.001) were found to decrease risk of reintubation. CONCLUSIONS: Across three complementary data sets, incidence of reintubation within one day of ACDF was approximately 0.20%. Increased risk of reintubation associated with anticoagulant administration suggests upper airway hematoma as an underlying etiology. Steroid administration and delayed extubation may be useful in patients considered to be at higher risk for reintubation.

Increased Use of Intra-Articular Steroid Injection to Treat Osteoarthritis is Associated With Chronic Opioid Dependence After Later Total Knee Arthroplasty But Not Total Hip Arthroplasty.

BACKGROUND: Intra-articular (IA) injections of corticosteroid (CO) and hyaluronic acid (HA) are commonly used for osteoarthritis. The efficacy of these interventions is controversial. Furthermore, research regarding the potential association of IA injection with later postoperative pain trajectories is lacking. METHODS: We performed analysis on Truven Health MarketScan database (2012-2016) in total hip arthroplasty (THA) and total knee arthroplasty (TKA). Trends over time were assessed. Multivariable logistic regression analyses were executed to evaluate the impact of IA injections on postoperative chronic opioid use. RESULTS: Preoperative CO and HA injections decreased throughout the study period in both THA and TKA. Preoperative CO and HA injections, regardless of frequency, had no significant impact on the odds of THA patients becoming chronic opioid users postoperatively. TKA patients who had 1 CO injection in the year before surgery experienced lower odds of postoperative chronic opioid use (odds ratio [OR], 0.89; 95% confidence interval [95% CI], 0.82-0.97), whereas patients who had 2 or more CO injections experienced significantly greater odds (OR, 1.14; 95% CI, 1.04-1.24). TKA patients who received 2 or more HA injections before surgery had significantly lower odds of chronic opioid use (OR, 0.90; 95% CI, 0.81-0.99). CONCLUSION: The utilization of IA injections in patients with hip and knee osteoarthritis appears to be decreasing over time. TKA patients who received 2 or more preoperative CO injections experienced greater odds of chronic opioid utilization, whereas TKA patients with 2 or more HA injections in the year before surgery had decreased odds of chronic opioid use.

Bilateral Total Knee Arthroplasty and In-Hospital Opioid Dispension: A Population-Based Study.

BACKGROUND: There is paucity of data regarding opioid dispension in patients undergoing bilateral total knee arthroplasty (BTKA). Our aim is to compare in-hospital opioid dispension between BTKA and unilateral TKA (UTKA) and to identify other factors associated with opioid dispension in the BTKA and UTKA cohorts. METHODS: Patients receiving elective TKA from 2006 to 2016 were retrospectively extracted from the Premier Healthcare Database. The effect of interest was bilateral TKA. Our primary outcome was in-hospital opioid dispension in oral morphine equivalents. Univariable statistics between study variables and TKA type were obtained. A multilevel logistic regression model was run for the outcome of high opioid dispension. RESULTS: A total of 1,029,120 patients were included. Among these, 14,469 (1.4%) underwent a BTKA. Within the 10-year period studied, there was a decrease in opioid dispension in both groups. Logistic regression analysis showed that patients treated with BTKA had 1.68 times higher odds for high opioid dispension compared to UTKA patients (odds ratio = 1.68; 95.5% confidence interval = 1.62, 1.75; P < .0001). White race, longer length of stay, Charlson/Deyo index, type of insurance, rural location, general anesthesia, peripheral nerve block use, and patient-controlled analgesia were also associated with high opioid dispension. Conversely, a more recent year of surgery, female gender, older age, and administration of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors were associated with lower odds for high opioid dispension. CONCLUSION: BTKA patients have increased odds for higher in-hospital opioid dispension compared to UTKA recipients. Utilization and prescribing habits should be examined to determine the optimal approach to opioid prescription in BTKA patients compared to UTKA.

Modifiable Analgesia-/Anesthesia-Related Factors and Risk of Severe Gastrointestinal Complications After Lower Extremity Total Joint Arthroplasty: A Nationwide Analysis.

BACKGROUND: Severe gastrointestinal (GI) complications after elective hip and knee arthroplasty (THA/TKA) are rare. Some of them can be life-threatening and/or require emergency abdominal surgery. We studied the epidemiology of severe GI complications after THA/TKA and associations with anesthesia- and/or analgesia-related factors. METHODS: We included 591,865 THA and 1,139,616 TKA cases (Premier Healthcare claims database; 2006-2016). Main outcomes were GI complications and related emergency surgeries within 30 days after THA/TKA. Anesthesia- and analgesia-related factors were anesthesia type (neuraxial, general), use of peripheral nerve block, patient-controlled analgesia, nonopioid analgesics (acetaminophen, gabapentin/pregabalin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, ketamine), and opioids (in oral morphine equivalents, categorized into low, medium, and high use based on the interquartile range). Mixed-effects models measured associations between anesthesia- and analgesia-related factors and outcomes, which were reported using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Among THA patients, GI complications were observed in 1.03% (n = 6103), with 0.08% (n = 450) requiring emergency surgery; this was 0.79% (n = 8971) and 0.05% (n = 540), respectively, for TKA patients. After adjustment for relevant covariates (including opioid use), almost all anesthesia-/analgesia-related factors were associated with significantly decreased odds of GI complications, specifically use of cyclooxygenase-2 inhibitors (OR 0.72 CI 0.67-0.76/OR 0.82 CI 0.78-0.86), nonsteroidal anti-inflammatory drugs (OR 0.81 CI 0.77-0.85/OR 0.90 CI 0.86-0.94), and peripheral nerve blocks (OR 0.77 CI 0.69-0.87/OR 0.91 CI 0.85-0.97); all for THA and TKA, respectively (all P < .01). CONCLUSION: Rare, but devastating, acute GI complications (requiring surgery) after THA/TKA may be positively impacted by a variety of modifiable anesthesia-/analgesia-related interventions.

Anaesthesia provider volume and perioperative outcomes in total joint arthroplasty surgery.

BACKGROUND: While increased surgical-provider volume has been associated with improved outcomes, research regarding volume-outcome relationships within high-volume institutions and the role of anaesthesiologists is limited. Further, the effect of anaesthesia-care-team composition remains understudied. This analysis aimed to identify the impact of anaesthesiologist and surgeon volume on adverse events after total joint arthroplasties. METHODS: We retrospectively identified 40 437 patients who underwent total joint arthroplasties at a high-volume institution from 2005 to 2014. The main effects of interest were anaesthesiologist and surgeon volume and experience along with anaesthesia-care-team composition. Multivariable logistic regression models were used to evaluate three outcomes: any complication, cardiopulmonary complication, and length of stay (>5 days). Odds ratios (ORs) and 99.75% confidence intervals (CIs) were reported. RESULTS: Across all three models, anaesthesiologist volume and experience, and anaesthesia-care-team composition were not significant predictors. Surgeon annual case volume >50 was associated with significantly reduced odds of any complication (annual case volume: 50-149; OR: 0.80; CI: 0.66-0.98) and prolonged length of stay (OR: 0.69; CI: 0.60-0.80). Surgeon experience >20 yr was associated with significantly reduced odds of prolonged length of stay (OR: 0.85; CI: 0.75-0.95). CONCLUSIONS: Anaesthesiologist volume and experience, and anaesthesia-care-team composition did not impact the odds of an adverse outcome, although a higher surgeon volume was associated with decreased odds of complications and prolonged length of stay. Further study is necessary to determine if these findings can be extrapolated to less specialised, lower volume surgical settings.

The impact of anesthesia and surgical provider characteristics on outcomes after spine surgery.

PURPOSE: Information regarding the impact of provider characteristics on perioperative outcomes in the spine surgery setting is limited. Existing studies primarily consider the impact of surgical provider volume. This analysis sought to identify the impact of anesthesiologist and surgeon volume and experience as well as anesthesia care team composition on adverse outcomes following anterior cervical discectomy and fusions (ACDF) and posterior lumbar fusions (PLF). METHODS: We identified 5900 patients who underwent ACDF or PLF procedures at a high-volume orthopedic institution from 2005 to 2014. Provider characteristics of interest were anesthesiologist and surgeon volume and experience along with anesthesia care team composition. Multivariable logistic regression models were used to evaluate the outcomes of any complication, cardiopulmonary complication, and prolonged length of stay (> 7 days). Intraclass correlation coefficients were calculated to determine how much variation in outcomes could be explained by provider characteristics. RESULTS: There were no significant relationships between provider characteristics and perioperative outcomes among ACDF patients. Within the PLF cohort, surgeon annual case volume > 25 was associated with decreased odds of prolonged length of stay, while anesthesia resident involvement was associated with increased odds of prolonged length of stay. Surgeon characteristics explained the greatest proportion of variation in outcomes while anesthesiologist characteristics explained the least. CONCLUSIONS: Anesthesia provider volume and experience did not significantly impact the odds of adverse outcome for ACDF and PLF patients. Higher surgeon volume was exclusively associated with decreased odds of prolonged length of stay following PLF. Further study is necessary to determine if these relationships persist in a less-specialized setting. These slides can be retrieved under Electronic Supplementary Material.

Cost of Care for Patients With Pre-Existing Comorbidities Undergoing Total Joint Arthroplasty: A Retrospective Cohort Study Evaluating Disease-Specific Perioperative Care.

BACKGROUND: Investigations suggest a relationship between increased resource utilization with disease burden and advanced age. However, it remains unknown the degree increased resource utilization is associated with pre-existing conditions, before complications occur. METHODS: This retrospective study identified total hip/knee arthroplasty cases in the Premier Database from 2006 to 2016 (N = 1,613,744), with hospitalization cost as the primary outcome. With a variable combining the conditions and complication, generalized linear models measured associations between condition/complication interaction groups and hospitalization cost. Estimates of percent cost increase by variable were obtained. RESULTS: Across all conditions, an increase in cost ranging from 0.38% to 4.28% was found in the absence of a complication. The "Condition = No, Complication = Yes" group was associated with a range of 11.50%-12.40% increase in average hospitalization cost, and the range was 14.43%-30.85% for the "Condition = Yes, Complication = Yes" group. CONCLUSION: We found that having a high-risk condition without a complication accounted only for a modest hospitalization cost increase.