The Primary Cost Drivers of Outpatient Distal Radius Fracture Fixation: A Cost-Minimalization Analysis of 15,379 Cases.

Background Distal radius fractures are the most common fracture of the upper extremity. While some distal radius fractures can be managed with closed reduction and immobilization, operative treatment is the standard of care, with open reduction internal fixation (ORIF) as a predominant operative method. Questions/Purpose To investigate how patient and surgical characteristics affect the overall costs of internal fixation of distal radius fractures in adults. Patients and Methods The 2014 State Ambulatory Surgery and Services Databases for six states were used to identify cases and surgical characteristics of distal radius fracture ORIF in adult patients. Results Surgical variables that significantly increased cost were postoperative admission within 30 days, regional anesthesia, simultaneous endoscopic carpal tunnel release, and increasing operating room time. Conclusion Substantial contributors to total cost are postoperative hospital admission within 30 days of surgery, use of regional anesthesia, simultaneous endoscopic carpal tunnel release, and longer operative time. Level of Evidence Level III, retrospective cohort study.

A quality assessment of YouTube content on shoulder instability.

OBJECTIVES: The Internet is a widely used resource for patients seeking health information, yet little editing or regulations are imposed on posted material. We sought to assess the quality and accuracy of information presented on shoulder instability on the online video platform YouTube. We hypothesize that YouTube videos concerning shoulder instability will be of little quality, accuracy, and reliability. METHODS: The first 50 YouTube videos resulting from the keyword query 'shoulder instability' were analyzed. The Journal of American Medical Association (JAMA) benchmark criteria (score range, 0-4) was used to assess video accuracy and reliability, and the Global Quality Score (GQS; score range, 0-5) was used to assess the quality of the video's educational content along with a generated Shoulder-Specific Score (SSS). RESULTS: The 50 videos observed collectively had 5,007,486 views, with the mean number of views being 100,149.72 ± 227,218.04. Of all videos observed, 32% were from a medical source and 56% had content relating to pathology information. The mean JAMA score was 2.84 ± 0.74, with the highest scores coming from academic sources. The mean GQS and SSS scores were 2.68 ± 0.84 and 5.30 ± 3.78. The mean GQS score was highest in videos from medical sources (3.3 ± 0.8) and videos about surgical technique/approach (3.2 ± 1.1). Advertisements were negative predictors of the JAMA score (ß = -0.324, P = 0.014), and academic (ß = 0.322, P = 0.015) and physician sources (ß = 0.356, P = 0.008) were positive predictors. CONCLUSION: YouTube videos on shoulder instability are of low quality and accuracy and are not reliable. Care providers should be aware of the overall low quality of information available on YouTube regarding shoulder instability.

Predictors of Surgery and Cost of Care Associated with Patellar Instability in the Pediatric and Young Adult Population.

PURPOSE: To determine how patient demographics, socioeconomic status, history of recurrence, and initial point of presentation for health care influenced the decision for surgical treatment following a patellar instability episode. METHODS: The New York SPARCS database from 2016 to 2018 was queried for patients aged 21 and younger who were diagnosed with a patellar instability episode. These were linked to later surgeries with Current Procedural Terminology (CPT) codes 27405 (MPFL repair), 27418 (tibial tubercle osteotomy), 27420 (dislocating patella reconstruction), 27422 (Campbell/Roux-Goldthwait procedure), and 27427 (extra-articular knee ligamentous reconstruction). χ2-analysis and binary logistic regression were used to assess demographic and injury-specific variables for association with operative management. A generalized linear model was used to estimate charges associated with patellar instability. RESULTS: There were 2,557 patients with patellar instability, 134 (5.2%) of whom underwent surgery. Patients with recurrent instability had 1.875 times higher odds of undergoing surgery (P = .017). Compared to white patients, black patients had 0.428 times the odds of surgery (P = .004). None of the patients without insurance had surgery. In the cost model, an initial visit to an outpatient office was associated with $1,994 lower charges compared to an emergency department (ED) visit (P < .001). Black patients had $566 more in charges than White patients (P = .009). Compared with nonoperative treatment, surgeries with CPT 27405 added $13,124, CPT 27418 added $10,749, CPT 27422 added $18,981, CPT 27420 added $23,700, and CPT 27427 added $25,032 (all P < .001). CONCLUSIONS: Patients with recurrent instability had higher odds of surgery, while Black and uninsured patients had lower odds of surgery. ED visits were associated with significantly higher charges compared to office visits, and Black patients had higher charges than white patients. Minority and uninsured patients may face barriers in access to orthopedic care. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Increased Total Cost and Lack of Diagnostic Utility for Emergency Department Visits After ACL Injury.

BACKGROUND: Patients are commonly evaluated at the emergency department (ED) with acute anterior cruciate ligament (ACL) tears, but providers without orthopaedics training may struggle to correctly diagnose these injuries. HYPOTHESIS: It was hypothesized that few patients would be diagnosed with an ACL tear while in the ED and that these patients would be of lower socioeconomic status and more likely to have public insurance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The 2017 State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) from the state of Florida were utilized in this study. Cases with Current Procedural Terminology code 29888 (arthroscopically aided ACL reconstruction [ACLR]) were selected from the SASD, and data from the SEDD were matched to patients who had an ED visit for a knee injury within 120 days before ACLR. Chi-square analysis was used to test for differences in patient and surgical variables between the ED visit and nonvisit patient groups. A generalized linear model was created to model the effect of ED visit on total cost for an ACL injury. RESULTS: While controlling for differences in patient characteristics and concomitant procedure usage, a visit to the ED added $4587 in total cost (P < .001). The ED visit cohort contained a greater proportion of patients with Medicaid (20.2% vs 9.1%), patients who were Black (18.4% vs 10.3%), and patients in the lowest income quartile (34.4% vs 25.0%) (P < .001 for all). In the ED visit cohort, 14.4% of patients received an allograft versus 10.1% in the non-ED visit cohort (P = .001) despite having a similar mean age. An ACL sprain was diagnosed in only 29 of the 645 (4.5%) patients who visited the ED. CONCLUSION: Utilizing the ED for care after an ACL injury was expensive, averaging a $4587 increase in total cost associated with ACLR. However, patients rarely left with a definitive diagnosis, with only 4.5% of patients who underwent ACLR being correctly diagnosed with an ACL tear in the ED. This additional cost was levied disproportionately on patients of low socioeconomic status and patients with Medicaid.

Cost Comparison of Open and Arthroscopic Treatment Options for SLAP Tears.

PURPOSE: To identify cost drivers of open biceps tenodesis, arthroscopic biceps tenodesis, and arthroscopic SLAP repair in the setting of isolated SLAP tears and to perform a direct cost comparison between the procedures. METHODS: The 2014 State Ambulatory Surgery and Services Databases from 6 US states were used. Cases with Current Procedural Terminology codes 23430 (tenodesis of long tendon of biceps), 29807 (shoulder arthroscopy, repair of SLAP lesion), and 29828 (shoulder arthroscopy, biceps tenodesis) were selected, excluding patients who were >50 years old or had a concomitant rotator cuff repair. Generalized linear models were used to model costs based on surgical and patient variables. RESULTS: The mean patient age was 41.8 years for open biceps tenodesis, 31.6 for arthroscopic SLAP repair, and 41.3 for arthroscopic biceps tenodesis (P < .001). Open biceps tenodesis had cost reductions of $5,664 over arthroscopic biceps tenodesis (P = .001) and $2,320 over arthroscopic SLAP repair (P = .043). Male sex was associated with $3,798 more in costs (P < .001), presence of ≥1 comorbidities added $1,829 (P = .002), and each minute in the operating room added $37 (P < .001). Operative time for open biceps tenodesis averaged 114 minutes, and both arthroscopic procedures averaged 94 minutes (P < .001). Low-volume facilities were associated with $5,536 higher costs for arthroscopic biceps tenodesis (P = .001). CONCLUSION: In patients aged ≤50 years with isolated SLAP tears, open biceps tenodesis provides cost savings over arthroscopic methods of treatment. There was no significant cost difference between arthroscopic SLAP repairs and arthroscopic biceps tenodesis. Given the increased emphasis on cost containment, surgeons should be aware of the procedural costs associated with the treatment of SLAP tears. LEVEL OF EVIDENCE: III, retrospective cohort study.

Socioeconomic and Demographic Disparities in Early Surgical Stabilization Following Emergency Department Presentation for Shoulder Instability.

PURPOSE: To describe which patients are the most likely to undergo surgical management within the same calendar year as their emergency department visit for anterior shoulder instability. METHODS: The State Emergency Department Databases and State Ambulatory Surgery and Services Databases from Florida were used. All patients presenting to the emergency department for anterior shoulder subluxation or dislocation between January 1 and September 30, 2017, were selected. Bivariate analysis was performed for associations with demographic variables. A binary logistic regression was performed with all significant factors to assess which were predictors of undergoing surgery the same calendar year. RESULTS: While controlling for all significant factors, we found that patients with recurrent dislocations were 3.14 times more likely to have surgery within the same year (P = .037). Patients younger than 40 years were also 2.04 times more likely to have surgery than those aged 40 years or older (P < .001). White patients were 2.47 times more likely to have surgery than black patients (P < .001). On bivariate analysis, there was an association between greater income quartile and higher odds of undergoing surgery within 30 days. CONCLUSIONS: Following an emergency department visit for acute shoulder instability, the following variables were associated with undergoing surgical stabilization within the same calendar year: previous dislocation, age younger than 40, and white race. Patients living in the greatest income quartile of patients had a significantly greater percentage of patients having surgery within 30 days. This demonstrates that disparities and barriers to care may exist for patients with shoulder instability. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Cost comparison of arthroscopic rotator cuff repair with arthroscopic vs. open biceps tenodesis.

PURPOSE: To use a nationwide database to determine differences in cost between patients who underwent arthroscopic rotator cuff tear with open vs. arthroscopic biceps tenodesis (BT). METHODS: The 2014 State Ambulatory Surgical and Services Databases from 6 US states was utilized. All cases with CPT codes 29827 (arthroscopic rotator cuff repair [RCR]) and either 23430 (tenodesis of long tendon of biceps) or 29828 (arthroscopic BT) were selected. Cases that included both 23430 and 29828 were excluded, as were those missing demographic data. Generalized linear models were used to model costs based on the surgical and patient variables that were significant in the initial bivariate analysis (P < .05). RESULTS: A total of 3635 RCR and BT cases were identified. There were 2847 (78.3%) with arthroscopic BT and 788 (21.7%) with open BT. Patients undergoing arthroscopic BT were 3.1 years older than patients undergoing open BT (P < .001). For arthroscopic BT, 39.2% of the cases were women compared with 22.6% of the open cases (P < .001). For operative variables, arthroscopic BT required 9 fewer minutes in the OR than open cases (P = .002). Concomitant distal clavicle resection was performed in 35.5% of arthroscopic BT cases compared with 29.8% of open cases (P = .004). While controlling for other significant factors, open BT was associated with $5542 lower costs than arthroscopic BT in the setting of RCR (P < .001). In either case, concomitant subacromial decompression added $10,669 (P < .001), and distal clavicle resection added $3210 (P < .001). High-volume surgical facilities were associated with $4107 lower costs (P < .001). CONCLUSIONS: In a large series of patients undergoing arthroscopic RCR with open vs. arthroscopic BT, open BT was associated with $5542 lower costs than arthroscopic. Given that both techniques have been shown to be similarly effective in long-term follow-up, surgeons should be aware of opportunities for cost saving, particularly with the advent of bundled surgical reimbursements.

Decline in Racial Disparities for United States Hospital Admissions After Anterior Cruciate Ligament Reconstruction From 2007 to 2015.

BACKGROUND: Racial disparities in perioperative complications have been shown to exist for many procedures in orthopaedic surgery. Although anterior cruciate ligament reconstruction (ACLR) is commonly performed as an outpatient procedure, the rate of admission to the hospital postoperatively is not insignificant. Hispanic patients have been shown to have higher odds of admission compared with non-Hispanic patients. HYPOTHESIS: We hypothesized that racial disparities would decrease from 2007 to 2015, resulting in lower rates of hospital admission for Black and Hispanic patients. STUDY DESIGN: Descriptive epidemiology study. METHODS: This study represents a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database for patients undergoing ACLR between 2007 and 2015. We performed bivariate analysis as well as binary logistic regression, with postoperative admission as the primary outcome. Previously identified risk factors for admission were used as predictors in addition to a term for the statistical interaction between year of surgery and ethnicity. RESULTS: A total of 7542 patients undergoing ACLR were assessed. The logistic regression model showed that Hispanic patients had higher overall odds of admission (odds ratio [OR], 3.320; P < .001) than White patients; Black patients also had higher odds compared with White patients (OR, 1.929; P = .009). However, there was a significant interaction between year of surgery and both Black ethnicity (OR, 0.907; P = .026) and Hispanic ethnicity (OR, 0.835; P = .002), indicating a significant decrease in the admission rates for these minority patients compared with White patients over time. Other risk factors for admission were the use of regional anesthesia (OR, 3.482; P < .001), bleeding disorders (OR, 5.064; P = .002), a higher body mass index (OR, 1.029; P < .001), and longer operative times (OR, 1.012; P < .001). More recent surgery was associated with lower odds of admission (OR, 0.826; P < .001). CONCLUSION: Admission rates after ACLR declined from 2007 to 2015. Black and Hispanic patients were more likely to be admitted overall, but they also saw a greater decrease in the odds of admission than White patients. This represents a reduction in disparity between the 2 groups and is a reassuring improvement in racial disparity trends after a common sports procedure.

Cost Drivers Associated With Anterior Shoulder Stabilization Surgery.

BACKGROUND: Arthroscopic Bankart repair, open Bankart repair, and the Latarjet procedure are common treatments for anterior shoulder instability; however, little is known of costs by patient- and surgeon-specific factors. This study aimed to identify areas where cost reduction may be achieved. HYPOTHESIS: Increased total charges will be associated with low-volume surgeons and surgical facilities, hospital-owned facilities, open surgical techniques, and patients with at least 1 comorbidity. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: The 2014 State Ambulatory Surgery and Services Databases from 6 states were utilized. There were 3 Current Procedural Terminology codes (23455, 23462, 29806) used to identify open Bankart repair, the Latarjet procedure, and arthroscopic Bankart repair, respectively. Patient demographic and surgical variables were evaluated on a univariate basis, and all significant factors were then included in the multiple linear regression to determine which factors had the largest effect on cost. Total charges billed for the encounter were used as a proxy for cost of surgery. RESULTS: For open Bankart repair, arthroscopic Bankart repair, and the Latarjet procedure, longer operative times increased costs, and high-volume surgical facilities had decreased charges. For the arthroscopic Bankart group, additional factors that increased charges included postoperative hospital admission (US$11,516; P < .001), patient residence in a ZIP code with a below-median income (US$2909; P < .001), presence of a comorbidity (US$1982; P < .001), male sex (US$1545; P = .003), Hispanic race (US$2493; P = .005), and use of regional anesthesia (US$1898; P = .025). Additional cost drivers for the Latarjet procedure included postoperative hospital admission (US$7028; P = .022) and older age (US$187/y; P = .039). CONCLUSION: Postoperative admission to the hospital was the largest cost driver for arthroscopic Bankart repair and the Latarjet procedure. Low-volume facilities were the largest cost driver for open Bankart repair. High-volume surgery centers had lower costs when compared with low-volume surgery centers. Regional anesthesia increased costs in the arthroscopic Bankart group. These findings may help to show where cost savings can be achieved, particularly considering increasing trends toward bundled health care payments.

High-Volume and Privately Owned Ambulatory Surgical Centers Reduce Costs in Achilles Tendon Repair.

BACKGROUND: While Achilles tendon repairs are common, little data exist characterizing the cost drivers of this surgery. PURPOSE: To examine cases of primary Achilles tendon repair, primary repair with graft, and secondary repair to find patient characteristics and surgical variables that significantly drive costs. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: A total of 5955 repairs from 6 states were pulled from the 2014 State Ambulatory Surgery and Services Database under the Current Procedural Terminology codes 27650, 27652, and 27654. Cases were analyzed under univariate analysis to select the key variables driving cost. Variables deemed close to significance (P < .10) were then examined under generalized linear models (GLMs) and evaluated for statistical significance (P < .05). RESULTS: The average cost was $14,951 for primary repair, $23,861 for primary repair with graft, and $20,115 for secondary repair (P < .001). In the GLMs, high-volume ambulatory surgical centers (ASCs) showed a cost savings of $16,987 and $2854 in both the primary with graft and secondary repair groups, respectively (both P < .001). However, for primary repairs, high-volume ASCs had $2264 more in costs than low-volume ASCs (P < .001). In addition, privately owned ASCs showed cost savings compared with hospital-owned ASCs for both primary Achilles repair ($2450; P < .001) and primary repair with graft ($11,072; P = .019). Time in the operating room was also a significant cost, with each minute adding $36 of cost in primary repair and $31 in secondary repair (both P < .001). CONCLUSION: Private ASCs are associated with lower costs for patients undergoing primary Achilles repair, both with and without a graft. Patients undergoing the more complex secondary and primary with graft Achilles repairs had lower costs in facilities with greater caseload.

Disparities in Cost and Access by Caseload for Arthroscopic Rotator Cuff Repair: An Analysis of 18,616 Cases.

BACKGROUND: Surgeon caseload has been shown to affect both health and economic outcomes in arthroscopic rotator cuff repair. Although previous studies have investigated disparities in access to care, little is known about disparities between low- and high-volume surgeons and facilities. PURPOSE: To identify where disparities may exist regarding access to high-volume surgeons and facilities. STUDY DESIGN: Cross-sectional study. METHODS: Univariate analysis was performed to analyze differences in the caseload between low- and high-volume surgeons and facilities. Cutoff values were set at 50 cases per year for high-volume surgeons and 125 cases annually for high-volume facilities. Multiple linear regression was then used to develop a cost model incorporating all variables significant under univariate analysis. We collected 18,616 cases with Current Procedural Terminology code 29827 ("arthroscopic rotator cuff repair") from the 2014 Florida State Ambulatory Surgery and Services Databases. RESULTS: A greater proportion of the caseload for low-volume surgeons and facilities was composed of patients who were of lower socioeconomic status, had government-subsidized insurance, or lived in areas with low-income ZIP codes. Low-volume surgeons and facilities also had higher total charges, higher postoperative admission rates, and lower distal clavicle excision rates (P < .001). In our cost model, a low facility volume significantly increased costs. Subacromial decompression, postoperative admission, distal clavicle excision, male sex, and government-subsidized insurance were all significant factors for increased costs in multivariate cost analysis. CONCLUSION: There are disparities in access to high-volume surgeons and facilities for patients undergoing arthroscopic rotator cuff repair in Florida. Patients with a lower socioeconomic status, government-subsidized insurance, and low income all faced decreased access to these high-volume groups. High-volume surgeons and facilities were associated with lower total charges, higher rates of distal clavicle excision, and lower readmission rates. Low-volume facilities added a significant amount of cost, even when controlling for all other significant variables. It is important for providers to be aware of these disparities and work to address them in their own practices.

The primary cost drivers of arthroscopic rotator cuff repair surgery: a cost-minimization analysis of 40,618 cases.

BACKGROUND: An estimated 250,000 rotator cuff repair (RCR) surgical procedures are performed every year in the United States. Although arthroscopic RCR has been shown to be a cost-effective operation, little is known about what specific factors affect the overall cost of surgery. This study examines the primary cost drivers of RCR surgery in the United States. METHODS: Univariate analysis was performed to determine the patient- and surgeon-specific variables for a multiple linear regression model investigating the cost of RCR surgery. The 2014 State Ambulatory Surgery and Services Databases were used, yielding 40,618 cases with Current Procedural Terminology code 29827 ("arthroscopic shoulder rotator cuff repair"). RESULTS: The average cost of RCR surgery was $25,353. Patient-specific cost drivers that were significant under multiple linear regression included black race (P < .001), presence of at least 1 comorbidity (P < .001), income quartile (P < .001), male sex (P = .012), and Medicare insurance (P = .035). Surgical factors included operative time (P < .001), use of regional anesthesia (P < .001), quarter of the year (January to March, April to June, July to September, and October to December) (P < .001), concomitant subacromial decompression or distal clavicle excision (P < .001), and number of suture anchors used (P < .001). The largest cost driver was subacromial decompression, adding $4992 when performed alongside the RCR. CONCLUSION: There are several patient-specific variables that can affect the cost of RCR surgery. There are also surgeon-controllable factors that significantly increase cost, most notably subacromial decompression, distal clavicle excision, use of regional anesthesia, and number of suture anchors. Surgeons must consider these factors in an effort to minimize cost, particularly as bundled payments become more common.

What Are the Primary Cost Drivers of Anterior Cruciate Ligament Reconstruction in the United States? A Cost-Minimization Analysis of 14,713 Patients.

PURPOSE: To analyze the individual costs associated with anterior crucial ligament reconstruction (ACLR), accounting for patient demographics, perioperative decision making, and location of the surgical procedure (hospital vs ambulatory surgery center), utilizing a cost-minimization analysis in a large national database. METHODS: Univariate analysis and multiple linear regression were performed to determine which patient and surgical variables were the largest cost drivers for ACLR in the United States according to the State Ambulatory Surgery and Services Database. RESULTS: The average cost for ACLR (n = 14,713) was $24,707 (standard deviation, $15,644). When patient variables were considered, younger age (P < .001), male sex (P < .001), Hispanic ethnicity (P < .001), number of chronic medical conditions (P < .001), Medicare insurance (P < .001), and quartile of household income (P < .001) were all associated with higher costs after ACLR. For operative variables, time spent in the operating room (P < .001), meniscal repair (P < .001), and use of general anesthesia alone (P < .001) were all associated with higher costs for ACLR. There was no significant difference between cost of surgery performed at a private surgery center and cost at a hospital-owned center. In the multivariate regression, the 3 variables with the greatest influence on cost of ACLR were use of isolated general anesthesia (associated with an increase of $2,049), Hispanic ethnicity ($1,828), and >1 chronic medical condition ($1,749). Male sex, time in operating room, and older age also significantly increased ACLR cost. CONCLUSIONS: The greatest contributor to cost of ACLR was the use of general anesthesia alone. Time spent in the operating room increased ACLR cost by $108 per minute. Patient factors included greater age, male sex, Hispanic ethnicity, number of chronic medical conditions, Medicare insurance, and annual income. Meniscal repair and regional nerve block did not significantly affect cost as determined by multivariate regression.

Tobacco Use and Complications Following Spinal Fusion: A Comparison of the National Surgical Quality Improvement Program and National Inpatient Sample Datasets.

BACKGROUND: Smoking is a known risk factor for inferior health outcomes. Retrospective analyses of large datasets may assess whether such risk is manifested or mitigated in clinical practice. Although many risk factor analyses use the National Surgical Quality Improvement Program (NSQIP) and National (Nationwide) Inpatient Sample (NIS), such investigations have seldom been directly compared. METHODS: NIS and NSQIP datasets were used. Primary outcome measures were perioperative complications. NSQIP complications were stratified based on occurrence before versus after discharge. Multiple logistic regression was employed in adjusted analyses. RESULTS: Among NSQIP (N = 56,145) and NIS (N = 1,311,426) patients, 24.0% and 31.8% were identified as tobacco users, respectively. Before discharge, NSQIP smokers had increased odds of pneumonia (adjusted odds ratio [aOR] = 1.43), postoperative intubation (aOR = 1.40), and sepsis (aOR = 1.71) and decreased odds of pulmonary embolism (aOR = 0.57) (all P < 0.05). After discharge, NSQIP smokers exhibited increased odds of cardiac arrest (aOR = 2.53) and surgical site infection (aOR = 1.25) and decreased odds of urinary tract infection (aOR = 0.68) and deep venous thrombosis (aOR = 0.61) (all P < 0.05). In adjusted analysis of NIS data, tobacco users exhibited increased odds of inpatient pneumonia (aOR = 1.57), myocardial infarction (aOR = 1.29), and postoperative intubation (aOR = 1.15) and decreased odds of pulmonary embolism (aOR = 0.80) and deep venous thrombosis (aOR = 0.78) (all P < 0.05). CONCLUSIONS: Patients with a history of tobacco use undergoing spinal fusion were at increased risk of pneumonia and intubation but decreased risk of deep venous thrombosis and pulmonary embolism during the inpatient postoperative stay. After discharge, smokers exhibited increased odds of cardiac arrest and surgical site infection. NIS and NSQIP results were similar, with 9 of 12 outcomes exhibiting identical inpatient conclusions. Qualitative comparison of NIS and NSQIP yields results that offer increased validity over single-source studies.

Factors influencing survival following hip fracture among octogenarians and nonagenarians in the United States.

INTRODUCTION: Hip fractures account for a significant disease burden in the Unites States. With an aging population, this disease burden is expected to increase in the upcoming decades. MATERIALS AND METHODS: This represents a retrospective cohort study to assess mortality following hip fracture in the octogenarian and nonagenarian populations. Odds ratios for postoperative mortality were constructed using normalized patients from United States Social Security death tables. Kaplan Meier analysis and binary logistic regression were used to assess the impact of surgical delay and medical comorbidity (measured by the Carlson Comorbidity Index (CCI)) on postoperative mortality. RESULTS: 189 octogenarians and 95 nonagenarians were included. One-year mortality was nearly three times higher for both the octogenarians (OR: 3.1) and nonagenarians (OR: 3.14), and returned to that of the normal population 4 years post-op for octogenarians and 5 years post-op for nonagenarians. Higher preoperative medical comorbidity (CCI) was associated with higher post-op mortality for both octogenarians (log rank = 0.026) and nonagenarians (log rank = 0.034). A 48-h surgical delay resulted in significantly increased postoperative mortality among healthy patients (CCI of 0 or 1, OR: 18.1), but was protective for patients with significant medical comorbidity (CCI ≥ 3). Age, preoperative CCI, and 48-h surgical delay were all independent predictors of 1-year post-op mortality. CONCLUSIONS: Following hip fracture, there is a 3-fold increase in mortality for octogenarians and nonagenarians at 1 year post-op. A 48-h surgical delay significantly increased mortality for healthier patients but was protective against mortality for sicker patients.

Inpatient costs and blood transfusion rates of sarcopenic patients following thoracolumbar spine surgery.

OBJECTIVE Sarcopenia, the muscle atrophy associated with aging and disease progression, accounts for nearly $18.5 billion in health care expenditures annually. Given the high prevalence of sarcopenia in patients undergoing orthopedic surgery, the goal of this study was to assess the impact of sarcopenia on inpatient costs following thoracolumbar spine surgery. METHODS Patients older than 55 years undergoing thoracolumbar spine surgery from 2003 to 2015 were retrospectively analyzed. Sarcopenia was measured using total psoas area at the L-4 vertebra on perioperative CT scans. Hospital billing data were used to compare inpatient costs, transfusion rate, and rate of advanced imaging utilization. RESULTS Of the 50 patients assessed, 16 were sarcopenic. Mean total hospital costs were 1.75-fold greater for sarcopenic patients compared with nonsarcopenic patients ($53,128 vs $30,292, p = 0.04). Sarcopenic patients were 2.1 times as likely to require a blood transfusion (43.8% vs 20.6%, p = 0.04). Sarcopenic patients had a 2.6-fold greater usage of advanced imaging (68.8% vs 26.5%, p = 0.002) with associated higher diagnostic imaging costs ($2452 vs $801, p = 0.01). Sarcopenic patients also had greater pharmacy, laboratory, respiratory care, and emergency department costs. CONCLUSIONS This study is the first to show that sarcopenia is associated with higher postoperative costs and rates of blood transfusion following thoracolumbar spine surgery. Measuring the psoas area may represent a strategy for predicting perioperative costs in spine surgery patients.

Reported Litigation Associated With Primary Hip and Knee Arthroplasty.

BACKGROUND: Greater than 75% of arthroplasty surgeons report having been the subject of a malpractice lawsuit. Despite this, few studies have analyzed the causes of litigation following total joint arthroplasty in the United States. METHODS: This study is a retrospective analysis of malpractice lawsuits following total hip and knee arthroplasty using VerdictSearch, a database encompassing legal cases compiled from February 1988 to May 2015. Complications leading to litigation were categorized and assessed for patient, surgeon, and lawsuit factors. All monetary awards were reflected for inflation. RESULTS: A total of 213 lawsuits were analyzed (119 total hip and 94 total knee arthroplasty cases). Overall, 15.0% of cases ended in settlement and 29.6% ended in a verdict in favor of the plaintiff (physician loss). The average payment for cases lost in court ($1,929,822 ± $3,679,572) was significantly larger than cases that ended in settlement ($555,347 ± $822,098) (P = .006). The most common complication following hip arthroplasty was "nerve injury" (29 cases, settlement rate: 10.3%, physician loss rate: 53.9%, and average payment: $1,089,825). The most common complication following knee arthroplasty was "pain or weakness" (17 cases, settlement rate: 5.9%, physician loss rate: 6.3%, and average payment: $451,867). Technical complications were the most likely complications to result in a physician loss (P = .019). CONCLUSION: While complications like "pain and weakness" are less likely to result in favorable litigation for patients, the presence of an objective technical complication or nerve injury was associated with an increased risk of a physician loss and a higher payment.

Assessment of Malpractice Claims Associated With Acute Compartment Syndrome.

BACKGROUND: Because acute compartment syndrome is one of the few limb-threatening and life-threatening orthopaedic conditions and is difficult to diagnose, it is a frequent source of litigation. Understanding the factors that lead to plaintiff verdicts and higher indemnity payments may improve patient care by identifying common pitfalls. METHODS: The VerdictSearch legal claims database was queried for the term "compartment syndrome." After 46 cases were excluded for missing information or irrelevancy, 139 cases were reviewed. The effects of plaintiff demographics, mechanism of injury, and complications were assessed. RESULTS: Of 139 cases, 37 (27%) were settled, 69 (50%) resulted in a defendant ruling, and 33 (24%) resulted in a plaintiff ruling. Juries were more likely to rule in favor of juvenile plaintiffs than adult patients (P = 0.002) and female plaintiffs than male plaintiffs (P = 0.008), but indemnity payments were not affected by the age or sex of the plaintiff. Plaintiffs who experienced acute compartment syndrome as a complication of surgery were more likely to win their suit and receive higher awards (P < 0.05), compared with those in whom the condition developed as a result of trauma. Amputation or delay in diagnosis or treatment did not affect plaintiff verdicts or awards. CONCLUSION: Defendants were more likely to lose a lawsuit concerning the management of acute compartment syndrome if the patient was a woman or child or if acute compartment syndrome developed as a complication of a surgical procedure.