Do Patient-Reported Outcomes Reflect Objective Measures of Function? Implications for Total Knee Arthroplasty.

BACKGROUND: Patient-reported outcomes (PROs) are used in research, clinical practice, and by federal reimbursement models to assess outcomes for patients who have knee osteoarthritis (OA) and total knee arthroplasty (TKA). We examined a large cohort of patients to determine if commonly used PROs reflect observed evaluation as measured by standardized functional tests (SFTs). METHODS: We used data from the Osteoarthritis Initiative, a 10-year observational study of knee osteoarthritis patients. Two cohorts were examined: 1) participants who received TKA (n = 281) and 2) participants who have native OA (n = 4,687). The PROs included Western Ontario and McMaster Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), 12-Item Short Form Health Survey (SF-12), and Intermittent and Constant Pain Score (ICOAP). The SFTs included 20 m and 400 meter (m) walks and chair stand pace. Repeated measures correlation coefficients were used to determine the relationship between PROs and SFTs. RESULTS: The PROs and SFTs were not strongly correlated in either cohort. The magnitude of the repeated measures correlation (rrm) between KOOS, WOMAC, SF-12, and ICOAP scores and SFT measurements in native knee OA patients ranged as follows: 400 m walk pace (0.08 to 0.20), chair stand pace (0.05 to 0.12), and 20 m pace (0.02 to 0.21), all with P < .05. In the TKA cohort, values ranged as follows: 400 M walk pace (0.00 to 0.29), chair stand time (0.02 to 0.23), and 20 M pace (0.03 to 0.30). Due to the smaller cohort size, the majority, but not all had P values < .05. CONCLUSION: There is not a strong association between PROs and SFTs among patients who have knee OA or among patients who received a TKA. Therefore, PROs should not be used as a simple proxy for observed evaluation of physical function. Rather, PROs and SFTs are complementary and should be used in combination for a more nuanced and complete characterization of outcome.

Does Time to Reimplantation After Explant for Prosthetic Joint Infection Influence the Likelihood of Successful Outcomes at 2 Years?

BACKGROUND: Consensus recommendations are lacking regarding appropriate timing of reimplantation following 2-stage resection arthroplasty for prosthetic joint infections (PJIs). We investigated whether the time from resection arthroplasty to reimplantation was associated with treatment outcome at 2 years. METHODS: Retrospective cohort review was conducted for 101 patients undergoing resection arthroplasty with an antibiotic spacer for PJI at a single tertiary academic referral institution. Time from explantation and spacer placement to reimplantation was categorized into 3 groups: <12, 12-18, and >18 weeks. Baseline patient and treatment course characteristics across these groups were obtained. Multivariate binary logistic regression was used to characterize association between treatment failure and time to reimplantation, controlling for American Society of Anesthesiologists (ASA) score and prior revision surgery. RESULTS: Time to reimplantation (TTR) >18 weeks demonstrated statistically significant increased odds of treatment failure, after controlling for ASA score and prior revision surgery (odds ratio 7.00, confidence interval 2.14-25.42, P = .002). After excluding patients requiring second spacer or Girdlestone prior to replant, this increased odds of failure remained (odds ratio 4.12, confidence interval 1.18-15.37, P = .029). TTR groups were similar with respect to demographics, except for ASA (2.96 for time to reimplantation >18 weeks vs 2.55 for time to reimplantation <12 weeks; P = .011). Patients with TTR >18 weeks were more likely to have an unplanned readmission during the spacer period (48%, 19%, and 6% for time to reimplantation >18, 12-18, and 0-12 weeks, respectively; P < .002). CONCLUSION: Although decision regarding TTR is largely patient specific, surgeons should be aware that TTR >18 weeks may be associated with higher rates of treatment failure at 2 years.

Risk-Adjusted Cost Performance for 90-Day Total Hip Arthroplasty Episodes: Comparing US Hospitals Nationwide Before CJR.

BACKGROUND: We characterize variation in total hip arthroplasty (THA) episode payments in the United States. Medicare population immediately preceding implementation of the comprehensive care for joint replacement (CJR) bundled care model and propose a model for ongoing evaluation of hospital performance. METHODS: We identified THA episodes in Medicare part A 2014-2016 (n = 366,380) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed and region-level and hospital-level random effects. Random effects estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3218) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high-performing and low-performing hospitals. RESULTS: Mean part A episode payments declined from 2014 to 2016 throughout the United States ($19,925-$17,775; P < .001), primarily attributable to decreased postacute care payments. Ninety-day readmission rates fell by a percentage point (from 7.9% to 6.8%; P < .001). We found significant variation in risk-adjusted episode payments, postacute care utilization, and readmission rates across regions, and ever greater variation at the hospital level. CONCLUSION: Medicare part A payments decreased for THA episodes between 2014 and 2016. The time frame for this decrease is notable for preceding full implementation of CJR, thus suggesting a more universal embrace of value-based care principles before the start date of CJR. These decreases were primarily because of decreased postacute care utilization and possibly related to falling readmission rates. Yet, significant variation in hospital cost performance remains, even after risk adjustment.

Digital Orthopaedics: A Glimpse Into the Future in the Midst of a Pandemic.

BACKGROUND: The response to COVID-19 catalyzed the adoption and integration of digital health tools into the health care delivery model for musculoskeletal patients. The change, suspension, or relaxation of Medicare and federal guidelines enabled the rapid implementation of these technologies. The expansion of payment models for virtual care facilitated its rapid adoption. The authors aim to provide several examples of digital health solutions utilized to manage orthopedic patients during the pandemic and discuss what features of these technologies are likely to continue to provide value to patients and clinicians following its resolution. CONCLUSION: The widespread adoption of new technologies enabling providers to care for patients remotely has the potential to permanently change the expectations of all stakeholders about the way care is provided in orthopedics. The new era of Digital Orthopaedics will see a gradual and nondisruptive integration of technologies that support the patient's journey through the successful management of their musculoskeletal disease.

A biomechanical analysis of the soft tissue and osseous constraints of the hip joint.

PURPOSE: The goal of this study was to determine the role of soft tissue and osseous constraints in hip biomechanics using a unique robotic testing apparatus. METHODS: Four fresh-frozen human cadaveric hemi-pelvises without degenerative changes or dysplasia were stripped of all soft tissue except the ligamentous capsule and the intra-articular structures. All hips were tested using a robotic manipulator/universal force-moment sensor testing system to measure and compare end-range of motion (ROM) and kinematic translations in "capsule vented" (a small hole in the capsule) and "capsule separated" (capsular ligaments separated from each other) states. Then, the "capsule vented" state was compared to the condition in which the capsule and labrum were removed to calculate bone and soft tissue forces with 40 N of load applied in six different directions along three axes. RESULTS: There were no significant differences in end-ROM or kinematic translations between the "capsule vented" and "capsule separated" states. Bone forces significantly increased with loads applied in the anterior, posterior and superior directions. Soft tissue forces increased significantly with loads applied in the medial, lateral and inferior directions. CONCLUSION: The individual hip capsular ligaments act independently of each other to resist end-ROM. Both osseous and soft tissue constraints are important to hip biomechanics depending upon the direction of applied force. The clinical relevance is that surgical management for hip disorders should preserve the soft tissue constraints in the hip when possible to maintain normal hip biomechanics.

An Algorithmic Approach to Understanding Osteoarthritic Knee Pain.

Background: Osteoarthritic knee pain is a complex phenomenon, and multiple factors, both within the knee and external to it, can contribute to how the patient perceives pain. We sought to determine how well a deep neural network could predict osteoarthritic knee pain and other symptoms solely from a single radiograph view. Methods: We used data from the Osteoarthritis Initiative, a 10-year observational study of patients with knee osteoarthritis. We paired >50,000 weight-bearing, posteroanterior knee radiographs with corresponding Knee Injury and Osteoarthritis Outcome Score (KOOS) pain, symptoms, and activities of daily living subscores and used them to train a series of deep learning models to predict those scores solely from raw radiographic input. We created regression models for specific score predictions and classification models to predict whether the modeled KOOS subscore exceeded a range of thresholds. Results: The root-mean-square errors were 15.7 for KOOS pain, 13.1 for KOOS symptoms, and 14.2 for KOOS activities of daily living. Modeling was performed to predict whether pain was above or below given pain thresholds, and was able to predict extreme pain (KOOS pain < 40) with an area under the curve (AUC) of 0.78. Notably, the system was also able to correctly predict numerous cases where the Kellgren-Lawrence (KL) grade assigned by the radiologist was 0 but patient pain was high, and cases where the KL grade was 4 but patient pain was low. Conclusions: A deep neural network can be trained to predict the osteoarthritic knee pain that a patient experienced and other symptoms with reasonable accuracy from a single posteroanterior view of the knee, even using low-resolution images. The system can predict pain and dysfunction that the traditional KL grade does not capture. Deep learning applied to raw imaging inputs holds promise for disentangling sources of pain within the knee from aggravating factors external to the knee. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Deep Learning and Imaging for the Orthopaedic Surgeon: How Machines "Read" Radiographs.

➤: In the not-so-distant future, orthopaedic surgeons will be exposed to machines that begin to automatically "read" medical imaging studies using a technology called deep learning. ➤: Deep learning has demonstrated remarkable progress in the analysis of medical imaging across a range of modalities that are commonly used in orthopaedics, including radiographs, computed tomographic scans, and magnetic resonance imaging scans. ➤: There is a growing body of evidence showing clinical utility for deep learning in musculoskeletal radiography, as evidenced by studies that use deep learning to achieve an expert or near-expert level of performance for the identification and localization of fractures on radiographs. ➤: Deep learning is currently in the very early stages of entering the clinical setting, involving validation and proof-of-concept studies for automated medical image interpretation. ➤: The success of deep learning in the analysis of medical imaging has been propelling the field forward so rapidly that now is the time for surgeons to pause and understand how this technology works at a conceptual level, before (not after) the technology ends up in front of us and our patients. That is the purpose of this article.

A comparison of in-hospital mortality risk conferred by high hospital occupancy, differences in nurse staffing levels, weekend admission, and seasonal influenza.

BACKGROUND: Hospital occupancy, nurse staffing levels, weekend admission, and seasonal influenza have all been shown to be associated with in-hospital mortality. Yet, no study has simultaneously compared the strength of associations of these 4 factors with in-hospital mortality. OBJECTIVE: To compare the risk of in-hospital mortality conferred by high hospital occupancy on admission, increased nurse staffing levels, weekend admission, and seasonal influenza. STUDY DESIGN: Retrospective cohort study of 166,920 patients admitted to 39 Michigan hospitals between 2003 and 2006. Participants were adults, age > or = 65 years, admitted through the emergency department with 6 common discharge diagnoses (acute myocardial infarction, congestive heart failure, stroke, pneumonia, hip fracture, gastrointestinal bleeding). We used logistic regression to compare the differences in the predicted probability of death conferred by each of the 4 factors, controlling for patient age, gender, discharge diagnosis, and comorbid conditions. RESULTS: Each of the 4 factors had a statistically significant, independent association with in-hospital mortality. Seasonal influenza conferred the greatest increase in absolute risk of in-hospital mortality (0.5 percentage points; 95% CI, 0.23-0.76), followed by weekend admission (0.32, 0.11-0.54), and high hospital occupancy on admission (0.24, 0.06-0.43). Increased nurse staffing levels decreased the absolute risk of mortality by 0.25 percentage points (0.04-0.48) for each additional full-time equivalent nurse per patient-day. CONCLUSION: Hospital occupancy, nurse staffing levels, weekend admission, and seasonal influenza all appear to be independently associated with in-hospital mortality, but to varying degrees in the current sample. These findings may guide hospital administrators as they consider factors that influence weekly and seasonal patient flow and capacity, as well as staffing.

Prioritizing quality improvement in vascular surgery.

BACKGROUND: Despite growing interest in quality improvement, there remains uncertainty about which procedures offer the most room for improvement in vascular surgery. To inform ongoing quality improvement initiatives, this study assessed the relative contribution of different procedures to overall morbidity, mortality, and excess length of stay in vascular surgery. STUDY DESIGN: Using data from ACS-NSQIP, all patients undergoing a vascular surgery operation in 2005 and 2006 (N = 16 096) were identified. Patients were placed in 29 distinct procedure categories based on CPT codes. First, we examined the procedures according to their relative contribution to overall morbidity and mortality. Then the procedures were assessed according to their contribution to overall excess length of stay. RESULTS: Four procedure types alone accounted for 72% of adverse events, 68% of excess hospital days, and 77% of the cases in the cohort. Lower extremity bypass graft accounted for the greatest share of adverse events (29%), followed by abdominal aortic reconstruction (20%), lower extremity amputation (16%), and carotid endarterectomy (8%). The remaining 25 procedure categories accounted for only 28% of adverse events and 23% of the cases in the cohort. CONCLUSIONS: A small number of procedure types account for a disproportionately large share of morbidity, mortality, and excess hospital stay in vascular surgery, primarily because top ranked procedure types are also the most commonly performed operations in the field. These procedure types represent obvious targets for ACS-NSQIP and other efforts aimed at measuring and improving the quality of vascular surgery.

Risk-Adjusted Cost Performance for 90-Day Total Knee Arthroplasty Episodes: Data and Methods for Comparing U.S. Hospitals Nationwide.

BACKGROUND: We propose a model to characterize the variation in total knee arthroplasty (TKA) episode payments in the U.S. Medicare population to establish a baseline prior to the full implementation of the Comprehensive Care for Joint Replacement (CJR) model. METHODS: We identified TKA episodes in Medicare Part A (100% sample) from 2014 to 2016 (n = 717,690) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed effects (age, sex, race, comorbidities) and region-level (U.S. Census Regions) and hospital-level random effects. Random-effect estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3,217) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high and low-performing hospitals. RESULTS: During this period, the mean Part A episode payments declined throughout the United States ($18,665 to $16,978; p < 0.001), primarily because of decreased post-acute care payments ($6,401 to $4,873; p < 0.0001). The 90-day readmission rates fell by nearly 20% (7.2% to 5.8%; p < 0.001). We found significant variation (p < 0.05) in risk-adjusted episode payments, post-acute care utilization, and readmission rates across regions and even hospitals. The share of hospitals in each geographic region that were low-performance outliers for episode payments ranged from 13% to 31% and those that were high-performance outliers ranged from 16% to 30%. CONCLUSIONS: Medicare Part A payments for TKA episodes were decreasing prior to the CJR model because of decreases in both post-acute care utilization and hospital readmissions. A significant variation in risk-adjusted hospital cost performance remained. Our results provide a baseline against which to measure the impact of alternative payment models and a methodology by which to measure hospital-level performance, which can be compared with peer hospitals and national benchmarks.

Development and Validation of Perioperative Risk-Adjustment Models for Hip Fracture Repair, Total Hip Arthroplasty, and Total Knee Arthroplasty.

BACKGROUND: Comparing outcomes across providers requires risk-adjustment models that account for differences in case mix. The burden of data collection from the clinical record can make risk-adjusted outcomes difficult to measure. The purpose of this study was to develop risk-adjustment models for hip fracture repair (HFR), total hip arthroplasty (THA), and total knee arthroplasty (TKA) that weigh adequacy of risk adjustment against data-collection burden. METHODS: We used data from the American College of Surgeons National Surgical Quality Improvement Program to create derivation cohorts for HFR (n = 7000), THA (n = 17,336), and TKA (n = 28,661). We developed logistic regression models for each procedure using age, sex, American Society of Anesthesiologists (ASA) physical status classification, comorbidities, laboratory values, and vital signs-based comorbidities as covariates, and validated the models with use of data from 2012. RESULTS: The derivation models' C-statistics for mortality were 80%, 81%, 75%, and 92% and for adverse events were 68%, 68%, 60%, and 70% for HFR, THA, TKA, and combined procedure cohorts. Age, sex, and ASA classification accounted for a large share of the explained variation in mortality (50%, 58%, 70%, and 67%) and adverse events (43%, 45%, 46%, and 68%). For THA and TKA, these three variables were nearly as predictive as models utilizing all covariates. HFR model discrimination improved with the addition of comorbidities and laboratory values; among the important covariates were functional status, low albumin, high creatinine, disseminated cancer, dyspnea, and body mass index. Model performance was similar in validation cohorts. CONCLUSIONS: Risk-adjustment models using data from health records demonstrated good discrimination and calibration for HFR, THA, and TKA. It is possible to provide adequate risk adjustment using only the most predictive variables commonly available within the clinical record. This finding helps to inform the trade-off between model performance and data-collection burden as well as the need to define priorities for data capture from electronic health records. These models can be used to make fair comparisons of outcome measures intended to characterize provider quality of care for value-based-purchasing and registry initiatives.

Relationship among radiographic ankle medial clear space, sex, and height.

The ankle medial clear space (MCS) is frequently measured to evaluate ankle stability after an injury. However, controversy exists regarding a threshold size that distinguishes a normal MCS from an abnormal MCS. A retrospective radiographic review of mortise ankle radiographs in the uninjured ankle was performed, with the goal of defining the relationship among patient height, sex, and radiographic ankle MCS. Forty-nine patients with normal mortise radiographs and with information on patient height available in the electronic medical chart were identified for inclusion. For men, mean±standard deviation (in millimeters) was 3.3±0.8 for MCS perpendicular (MCSp), 3.8±0.7 for MCS oblique (MCSo), and 3.8±0.5 for superior clear space (SCS). For women, mean±standard deviation was 2.3±0.6 for MCSp, 2.9±0.5 for MCSo, and 3±0.4 for SCS. Univariate analysis showed that all 3 variables (MCSp, MCSo, and SCS) were statistically different when men were compared with women (P<.0001). Bivariate regression models showed statistically significant (P<.001) positive relationships between each of the measures of clear space and height. In multivariate analysis, female sex alone was associated with a decrease in clear space. When evaluating isolated lateral malleolus fractures, clinicians should consider the patient's height and sex when measuring MCS and SCS to determine deltoid ligament competence. These data suggest that men and people of tall stature are at risk for a false-positive diagnosis of deltoid ligament rupture when previously published threshold MCS and SCS values, such as 4 mm or 5 mm, are used for diagnosis and operative indication.

Variation in the femoral bow: a novel high-throughput analysis of 3922 femurs on cross-sectional imaging.

OBJECTIVES: To evaluate femoral radius of curvature in a large sample of computed tomography scans to definitively determine the relationship between radius of curvature and femoral length, age, gender, ethnicity, body mass index and cortical thickness. METHODS: A retrospective review was conducted of the electronic medical records and advanced imaging of 1961 patients who underwent pulmonary embolism protocol computed tomography scans between December 1999 and March 2010. The computed tomography scans were imported from the clinical picture archiving and communication system archive into a research image archive and analysis system. Each scan was processed by an automated system that algorithmically determined bony landmarks, adjusted for body position within the scanner and measured the radius of curvature. RESULTS: The mean medullary radius of curvature of 3922 femurs was 112 cm (SD = 26 cm). The mean anterior radius of curvature of the femurs was 145 cm (SD = 55 cm). There was a moderately strong positive correlation (0.36-0.39) between femoral length and radius of curvature (P < 0.0001) that was not affected by age, body mass index, cortical thickness, gender, or ethnicity. No significant relationship was found between either gender or ethnicity and radius of curvature independent of femoral length. CONCLUSIONS: Differences in radius of curvature based on ethnicity and gender exist primarily because of the variation in average height, and therefore femur length, that exists between ethnic groups and genders. These data may prove useful in the design of safer intramedullary implants that accommodate a greater spectrum of anatomic variation.

Cloud-based preoperative planning for total hip arthroplasty: a study of accuracy, efficiency, and compliance.

As digital radiography becomes more prevalent, several systems for digital preoperative planning have become available. The purpose of this study was to evaluate the accuracy and efficiency of an inexpensive, cloud-based digital templating system, which is comparable with acetate templating. However, cloud-based templating is substantially faster and more convenient than acetate templating or locally installed software. Although this is a practical solution for this particular medical application, regulatory changes are necessary before the tremendous advantages of cloud-based storage and computing can be realized in medical research and clinical practice.

Prioritizing perioperative quality improvement in orthopaedic surgery.

BACKGROUND: Surgical quality improvement has received increasing attention in recent years, but it is not clear where orthopaedic surgeons should focus their efforts for the greatest impact on perioperative safety and quality. We sought to guide these efforts by prioritizing orthopaedic procedures according to those that generate the greatest number of adverse events. METHODS: We used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify all patients who had undergone an orthopaedic surgical procedure between 2005 and 2007 (n = 7970). Patients were assigned to forty-four unique procedure groups on the basis of the Current Procedural Terminology (CPT) codes. We first assessed the relative contribution of each procedure group to the overall number of adverse events in the first thirty postoperative days, and we followed that with a description of their relative contribution to an excess length of stay in the hospital. RESULTS: Ten procedures accounted for 70% of the adverse events and 65% of the excess hospital days. Hip fracture repair accounted for the greatest share of adverse events, followed by total knee arthroplasty, total hip arthroplasty, revision total hip arthroplasty, knee arthroscopy, laminectomy, lumbar/thoracic arthrodesis, and femoral fracture repair. No other procedure group accounted for >2% of the adverse events. CONCLUSIONS: Only a few procedures account for the vast majority of adverse events in the first thirty days following orthopaedic surgery. Concentrating quality-improvement efforts on these procedures may be an effective way for surgeons and other stakeholders to improve perioperative care and reduce costs in orthopaedic surgery. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Clinical outcomes after anterior cruciate ligament reconstruction: a meta-analysis of autograft versus allograft tissue.

BACKGROUND: Clinical outcomes of autograft and allograft anterior cruciate ligament (ACL) reconstructions are mixed, with some reports of excellent to good outcomes and other reports of early graft failure or significant donor site morbidity. OBJECTIVE: To determine if there is a difference in functional outcomes, failure rates, and stability between autograft and allograft ACL reconstructions. DATA SOURCES: Medline, Cochrane Central Register of Controlled Trials (Evidence Based Medicine Reviews Collection), Cochrane Database of Systematic Reviews, Web of Science, CINAHL, and SPORTDiscus were searched for articles on ACL reconstruction. Abstracts from annual meetings of the American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America were searched for relevant studies. STUDY SELECTION: INCLUSION CRITERIA FOR STUDIES WERE AS FOLLOWS: primary unilateral ACL injuries, mean patient age less than 41 years, and follow-up for at least 24 months postreconstruction. Exclusion criteria for studies included the following: skeletally immature patients, multiligament injuries, and publication dates before 1990. DATA EXTRACTION: Joint stability measures included Lachman test, pivot-shift test, KT-1000 arthrometer assessment, and frequency of graft failures. Functional outcome measures included Tegner activity scores, Cincinnati knee scores, Lysholm scores, and IKDC (International Knee Documentation Committee) total scores. RESULTS: More than 5000 studies were identified. After full text review of 576 studies, 56 were included, of which only 1 directly compared autograft and allograft reconstruction. Allograft ACL reconstructions were more lax when assessed by the KT-1000 arthrometer. For all other outcome measures, there was no statistically significant difference between autograft and allograft ACL reconstruction. For all outcome measures, there was strong evidence of statistical heterogeneity between studies. The sample size necessary for a randomized clinical trial to detect a difference between autograft and allograft reconstruction varied, depending on the outcome. CONCLUSIONS: With the current literature, only KT-1000 arthrometer assessment demonstrated more laxity with allograft reconstruction. A randomized clinical trial directly comparing allograft to autograft ACL reconstruction is warranted, but a multicenter study would be required to obtain an adequate sample size.

Prioritizing quality improvement in general surgery.

BACKGROUND: Despite growing interest in quality improvement, uncertainty remains about which procedures offer the most room for improvement in general surgery. In this context, we sought to describe the relative contribution of different procedures to overall morbidity, mortality, and excess length of stay in general surgery. STUDY DESIGN: Using data from the American College of Surgeons' National Surgery Quality Improvement Program (ACS-NSQIP), we identified all patients undergoing a general surgery procedure in 2005 and 2006 (n=129,233). Patients were placed in 36 distinct procedure groups based on Current Procedural Terminology codes. We first examined procedure groups according to their relative contribution to overall morbidity and mortality. We then assessed procedure groups according to their contribution to overall excess length of stay. RESULTS: Ten procedure groups alone accounted for 62% of complications and 54% of excess hospital days. Colectomy accounted for the greatest share of adverse events, followed by small intestine resection, inpatient cholecystectomy, and ventral hernia repair. In contrast, several common procedures contributed little to overall morbidity and mortality. For example, outpatient cholecystectomy, breast procedures, thyroidectomy, parathyroidectomy, and outpatient inguinal hernia repair together accounted for 34% of procedures, but only 6% of complications (and only 4% of major complications). These same procedures accounted for < 1% of excess hospital days. CONCLUSIONS: A relatively small number of procedures account for a disproportionate share of the morbidity, mortality, and excess hospital days in general surgery. Focusing quality improvement efforts on these procedures may be an effective strategy for improving patient care and reducing cost.

National trends in adolescent bariatric surgical procedures and implications for surgical centers of excellence.

BACKGROUND: Bariatric surgery is indicated for severely obese adolescents who have failed nonsurgical treatment. Our objective was to examine national trends in the use of bariatric operations among adolescents. STUDY DESIGN: The Kids' Inpatient Database was used to identify bariatric surgery patients in the pediatric population (age younger than 18 years) for 1997, 2000, and 2003. Patients were identified by procedure codes for bariatric operations with confirmatory diagnosis codes for obesity. Nationally representative estimates of trends in bariatric procedures, patient characteristics, hospital characteristics, and in-hospital complication rates were calculated. We augmented our analysis with the 2003 Nationwide Inpatient Sample, to ascertain hospitals' overall bariatric surgical volume (adolescents and adults). RESULTS: From 1997 to 2003, the estimated number of adolescent bariatric procedures performed nationally increased 5-fold from 51 to 282 (p < 0.01). More than 100 hospitals performed bariatric procedures on adolescents in 2003, most of which (87%) performed 4 or fewer adolescent bariatric operations annually. Operations were predominantly performed in adult hospitals (85%). Although most hospitals had high overall bariatric operation volumes (> 200 bariatric procedures for patients of any age), 39% of adolescent bariatric procedures were performed at lower-volume centers. Patients were predominantly Caucasian (68%) and female (72%), with a mean age of 16 years (minimum age 12 years). In-hospital complications occurred in 6% of patients. There were no in-hospital deaths. CONCLUSIONS: Our findings indicate a recent, rapid increase in the frequency of adolescent bariatric procedures. Most hospitals that performed bariatric procedures on adolescents had limited experience with adolescent bariatric patients, although many of these hospitals appear to have been experienced adult centers with high overall bariatric volume (adolescents and adults). Future research must better clarify the institutional qualifications considered mandatory for treatment of eligible adolescents.