Unpacking disparities in substance-related outcomes among racial, ethnic, sexual, and gender minoritized groups during adolescence and emerging adulthood.

OBJECTIVE: Alcohol and other drug (AOD) use increases substantially from adolescence to emerging adulthood, and recent longitudinal studies show disparities in AOD-related outcomes by racial and ethnic, as well as sexual and gender minority (SGM), identities. Greater insight is needed into how individual, social, and environmental contexts interact and affect such disparities, as well as why disparate outcomes are found across different domains (e.g., social, educational, economic), even after accounting for intensity of use. This commentary addresses these important and timely issues. METHOD: We provide a brief overview of the literature, including our own team's work over the last 14 years, to identify and understand disparities in AOD-related outcomes during adolescence and emerging adulthood across individuals with different racial and ethnic, and sexual and gender, identities. We then discuss paths forward to advance research and build a stronger evidence base, leading to the development and identification of effective interventions that can help mitigate disparities among historically marginalized adolescents and emerging adults. RESULTS: Existing research highlights the need for further longitudinal work in several areas, including addressing contextual factors at various levels (e.g., individual, social, environmental) that may contribute to outcomes for different groups of individuals, developing and testing culturally appropriate AOD-related services, giving greater consideration to intersectionality of multiple minority identities, and using novel statistical approaches to help improve the estimation of differences across smaller subgroups of individuals in existing cohorts. CONCLUSIONS: To inform prevention programming and policy for improving health and well-being of historically marginalized populations, it is important to continue our efforts to understand disparities in AOD-related outcomes using multidisciplinary, equity, and intersectionality lenses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Quality indicators in primary elective total hip and knee arthroplasty.

PURPOSE: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent a significant portion of healthcare spending and are high-priority for quality improvement initiatives. This study aims to develop quality indicators (QIs) in the care of primary elective THA and TKA patients. These QIs serve a number of purposes including documentation of the quality of care, objective comparisons of institutions/providers, facilitating pay-for-performance initiatives, and supporting accountability, regulation, and accreditation. METHODS: A guideline-based approach, initially described by Kötter et al., was utilized. Eight clinical practice guidelines (CPGs) were evaluated for candidate indicators (CIs). CIs with high-quality evidence and consensus statements were extracted. Eighteen additional CIs were included from previous work that evaluated quality improvement databases. Each CI and supporting evidence was submitted for independent review by an expert panel. The RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology was utilized and items were rated based on validity, reliability, and feasibility of measurement. After two rounds of ratings and ranking, a final ranked list of QIs was obtained. RESULTS: Fifty-six CIs were identified from the literature and CPGs or proposed by the expert panel. Two rounds of voting resulted in 12 total QIs that were deemed appropriate measures of high-quality care. The final 12 QIs were ranked by order of importance: use of peri-operative tranexamic acid, infusion of prophylactic antibiotics prior to inflation of tourniquet, appropriate post-operative venous thromboembolic prophylaxis, complication rate, rate of secondary procedure, readmission rate, early mobilization, average change of pre- to one year post-operative functional status, use of multimodal analgesia, use of neuraxial anesthesia, use of peri-articular injection in TKA, and use of pre-operative PO analgesia. CONCLUSION: This study is an expert opinion based on parameters observed in modern and high-quality academic settings. Twelve QIs are proposed to assess the quality of care in the peri-operative management of primary elective THA and TKA patients.

Mid-Term Performance of the First Mass-Produced Three-Dimensional Printed Cementless Tibia in the United States as Reported in the American Joint Replacement Registry.

BACKGROUND: Cementless tibial components have shown improvements in clinical performance compared to predicate designs, though evidence supporting mid-term performance and fixation is scarce. The purpose of this study is to determine the mid-term survivorships, revision rates, and reasons why 3-dimensional printed cementless tibial baseplates (3DTKAs) failed compared to other cementless as well as cemented tibial baseplates reported from the American Joint Replacement Registry (AJRR) data. METHODS: All primary total knee arthroplasty (TKA) cases performed in patients 65 years of age or older within the AJRR from January 2, 2012 through June 30, 2020 were queried. A total of 28,631 3DTKAs were identified from 428 institutions. These were compared to all other "aggregated cementless tibia" (n = 7,577) and "aggregated cemented tibia" (n = 550,133) cases. Centers for Medicare & Medicaid Services data over the same time period were merged with AJRR data to determine survivorship and patient-timed incident revision rates per 1,000 years. Failure reasons were tracked during this study period. RESULTS: At 60 months, Kaplan-Meier implant survivorship was 98.9% (CI 98.7-99.0), 98.3% (CI 97.9-98.6), and 98.4% (CI 98.4-98.5) in the 3DTKA, aggregate cementless, and cemented knee cohorts, respectively (P < .0001). Patient-timed incident revision rates were 3.11 (CI 2.75-3.53), 3.99 (CI 3.34-4.76), and 3.35 (CI 3.28-3.42) for those cohorts, which corresponds to a revision rate of 0.31%, 0.40%, and 0.34% per year. CONCLUSION: In this analysis, 3DTKA had favorable survivorship and lower revision rates compared to aggregate cementless and cemented TKAs implanted from the same national database during the same time period.

Disparities in functioning from alcohol and cannabis use among a racially/ethnically diverse sample of emerging adults.

BACKGROUND: Trajectory studies have consistently shown that alcohol and cannabis (AC) use during emerging adulthood (EA) affect functioning; however, few studies examine whether racial/ethnic disparities may occur at similar levels of use. METHODS: We conducted web-based surveys across five waves from mean age 18.3 through 22.6. The sample (N = 2945) is 55% female, 46% Hispanic, 23% Asian, 23% White, 6% multi-racial (MR)/other, and 2% Black. MEASUREMENTS: Past month substance use was defined as number of days used. Outcomes at age 22.6 included negative consequences, delinquency, physical ailments and health, depression and anxiety, peer relationship functioning, life satisfaction, employment, and education. RESULTS: Compared to White EAs, Hispanic, Asian, and MR/other EAs reported less initial alcohol use; Hispanic and Asian EAs reported less initial cannabis use, whereas Black EAs reported more cannabis use. Greater initial frequency and increased frequency of AC use were associated with poorer outcomes (e.g., worse mental health). In terms of disparities, compared to White EAs, Hispanic EAs reported poorer physical health at the same levels of AC use; Hispanic, Asian, and MR/other EAs reported greater alcohol consequences and delinquency; Black, Hispanic, Asian and MR/other EAs reported lower life satisfaction; and Hispanic and MR/other EAs were less likely to pursue education beyond high school (although Asian EAs were more likely). CONCLUSIONS: Findings emphasize that trajectories of AC use during EA are associated with a range of functional outcomes. Disparities in functioning at similar levels of AC use highlight the importance of reaching racially/ethnically diverse EAs with prevention and intervention programming.

Development and testing of a standardized pain interview assessment for use in post-acute care.

OBJECTIVES: Pain is highly prevalent among patients in post-acute care (PAC) settings and can affect quality of life, treatment outcomes, and transitions in care. Routine, accurate assessment of pain across settings is important for pain management and care planning; however, existing PAC assessment instruments do not assess patient pain in a standardized manner. METHODS: We developed and tested a set of pain interview data elements for use across PAC settings (skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, home health agencies) as part of a larger effort undertaken by the Centers for Medicare & Medicaid Services to develop standardized assessment data elements to meet the requirements of the IMPACT Act of 2014. The interview assessed six pain constructs: presence; frequency; interference with sleep; interference with rehabilitation therapies [if applicable]; interference with daily activities; worst pain; and pain relief from treatments/medications). A total of 3031 PAC patients at 143 PAC settings (across 14 U.S. geographic/metropolitan areas in 10 states) participated in a national field test of standardized data elements from November 2017 to August 2018. We assessed item response distributions, time to complete interviews, inter-assessor agreement, and, for a subset of patients, change in responses between admission and discharge assessments. We also conducted focus groups with nurse assessors about their experiences administering the items. RESULTS: For patients reporting any pain, average time to complete the pain interview was 3.1 min (SD = 1.3), and interrater reliability was excellent for all data elements (kappa range: 0.95-0.99). Findings were similar across types of PAC settings. Qualitative data from nurses emphasized ease of administration and high perceived clinical utility. CONCLUSION: Findings provide support for feasibility of implementing a standardized pain interview assessment in PAC settings. This tool can support tracking of patient needs across settings and interoperability of data in electronic medical records.

Standardized assessment of cognitive function, mood, and pain among patients who are unable to communicate.

BACKGROUND: Assessments of patients have sought to increase the patient voice through direct patient interviews and performance-based testing. However, some patients in post-acute care (PAC) are unable to communicate and cannot participate in interviews or structured cognitive tests. Therefore, we tested the feasibility and reliability of observational assessments of cognitive function, mood, and pain for patients who are unable to communicate in PAC settings. METHODS: We conducted a national test of observational assessments of cognitive function, mood, and pain in 143 PAC facilities (57 home health agencies, 28 Inpatient Rehabilitation Facilities, 28 Long-Term Care Hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. For the 548 patients identified as unable to make themselves understood, we assessed descriptive statistics, percent of missing data, time to complete, and inter-rater reliability (IRR) between paired research nurse and facility staff assessors. RESULTS: Most sampled non-communicative patients were administered all three observational assessments. Among assessed patients, overall missing data was high for some items within the Staff Assessment for Mental Status (2.9% to 33.5%) and Staff Assessment of Patient Mood (12.4% to 44.3%), but not the Observational Assessment of Pain or Distress (0.0% to 4.4%). Average time to complete the data elements ranged from 2.4 to 3.5 min and IRR was good to excellent for all items (kappa range: 0.74-0.98). CONCLUSION: The three observational data elements had acceptable reliability. Although results revealed varying feasibility, there was support for feasibility overall in terms of implementing a standardized observational assessment of pain for patients in PAC settings. Additional work is needed for the Staff Assessment for Mental Status and the Staff Assessment of Patient Mood to improve the observable nature of these data elements and enhance instructions and training for standardizing the assessments.

Alcohol use and cannabis use trajectories and sexual/gender minority disparities in young adulthood.

OBJECTIVE: Sexual and gender minority (SGM) young people may use alcohol or cannabis (A/C) at higher rates that non-SGM peers, but little is known about whether SGM young adults experience poorer health, psychosocial, and other outcomes at similar levels of A/C use. METHOD: We used longitudinal survey data from a community cohort recruited from California middle schools in 2008 (average age 11.5) and followed across 12 waves through 2020. Participants reported on past-month A/C use at each wave. Individuals also reported SGM status as well as outcomes in multiple domains in Wave 12. Sequelae of change models tested differences in intercept and slope for A/C use trajectories from Waves 1-12 across SGM groups, and simultaneously examined differences in outcomes by SGM status adjusting separately for A/C trajectories. RESULTS: SGM (n = 445) and non-SGM (n = 2,089) groups did not differ on baseline probability of A/C use. SGM individuals showed steeper increases in probability of cannabis but not alcohol use over time. Adjusting for trajectories of A/C use, SGM individuals had significant disparities relative to non-SGM peers with respect to: Employment and economic stability, criminal justice involvement, social functioning, subjective physical health, behavioral health, and perceived unmet mental health treatment need. CONCLUSIONS: At the same levels of A/C use from middle school through young adulthood, SGM individuals show disparities in multiple domains compared to non-SGM peers. Targeted efforts to reduce substance use in conjunction with other structural disadvantages experienced by SGM youths are needed to address the emergence of disparities in young adulthood. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Estimating the impact of state cigarette tax rates on smoking behavior: Addressing endogeneity using a natural experiment.

INTRODUCTION: Cigarette excise taxes are a well-established policy lever for reducing tobacco use. However, estimating the effect of taxes on smoking behavior can be confounded by endogeneity concerns such as selection. This study leverages a unique natural experiment -compulsory relocation of U.S. military service members to installations - to estimate the relationship between state cigarette taxes and smoking behavior without concerns about selection into environments. METHODS: The current study uses data from the Department of Defense's 2011 Health-Related Behaviors Survey and 2011 state cigarette excise taxes from the CDC STATE System. Logistic and Poisson regression analyses estimate the cross-sectional associations between state cigarette excise taxes and the following smoking behaviors: current cigarette smoking, frequency of smoking, heaviness of consumption, and cigarette cessation among individuals who smoked while at the current installation. RESULTS: Higher taxes are associated with lower odds of current cigarette smoking (AOR = 0.94; 95 % CI: 0.89-0.98), fewer smoking days per month among current cigarette smokers (IRR = 0.98, 95 % CI 0.97-0.996), and higher likelihood of quitting smoking among individuals who had smoked at their current installation (AOR = 1.14, 95 % CI 1.05-1.25). Taxes are not associated with the number of cigarettes smoked per day among current smokers. CONCLUSIONS: Exogenous assignment to installations in states with higher cigarette taxes is associated with lower likelihood of smoking and greater likelihood of quitting. Findings provide novel evidence in support of a causal impact of cigarette taxes on lower smoking levels among adults.

Conceptual approach to developing quality measures for transgender patients.

BACKGROUND: Valid and reliable quality measures can help catalyze improvements in health care. The care of transgender patients is ripe for quality measurement, as there is increasing awareness of the increasing prevalence of this population and the urgency of improving the health care they receive. While best practices may not exist for some aspects of transgender health care, other aspects are characterized by well-developed and highly evidence-based recommendations. Our objective was to create a list of potential quality measures for transgender care. METHODS AND RESULTS: In consultation with our advisory panel, which consisted of clinical and academic experts in transgender medicine, we selected eight prominent clinical practice guidelines of transgender health care for review. Our four team investigators carefully reviewed all eight clinical practice guidelines. Through the course of multiple consensus-building meetings, we iteratively refined items until we had agreed upon a list of forty potential quality measures, all of which met the criteria for quality measures set forth in the Center for Medicare and Medicaid Services Blueprint for developing quality measures. CONCLUSIONS: This manuscript explains the origin of the quality measures we developed, and also provides a useful roadmap to any group hoping to develop quality measures for a field that has not previously had any.

Graphical-based multivariate analysis for knee joint clinical and kinematic data correlation assessment.

A large amount of data including joint kinematics, joint kinetics, clinical and functional measurements constitutes the clinical gait analysis basis which is a process whereby quantitative gait information are collected to aid in clinical decision-making. Therefore, better understanding the relationship between the biomechanical and clinical data for the knee osteoarthritis (OA) patient is for a relevant importance. It's the purpose of this paper, which aims to analyze and visualize the correlation structure between biomechanical characteristics and clinical symptoms, and thus to provide an additional knowledge from the coupling of these parameters that will be useful for the pathology assessment of knee-joint disease in the end-staged knee OA patients. We perform two multivariate statistical approaches, first, a Canonical Correlation Analysis (CCA) to assess the multivariate association and, second, a graphical- based representation of the multivariate correlation to better understand the association between these multivariate data. Results show the usefulness of using such multivariate approaches to highlight association and specific correlation structure between the features and to extract meaningful information.

Beyond Gender Identity Disorder Diagnoses Codes: An Examination of Additional Methods to Identify Transgender Individuals in Administrative Databases.

BACKGROUND: Large administrative databases often do not capture gender identity data, limiting researchers' ability to identify transgender people and complicating the study of this population. OBJECTIVE: The objective of this study was to develop methods for identifying transgender people in a large, national dataset for insured adults. RESEARCH DESIGN: This was a retrospective analysis of administrative claims data. After using gender identity disorder (GID) diagnoses codes, the current method for identifying transgender people in administrative data, we used the following 2 strategies to improve the accuracy of identifying transgender people that involved: (1) Endocrine Disorder Not Otherwise Specified (Endo NOS) codes and a transgender-related procedure code; or (2) Receipt of sex hormones not associated with the sex recorded in the patient's chart (sex-discordant hormone therapy) and an Endo NOS code or transgender-related procedure code. SUBJECTS: Seventy-four million adults 18 years and above enrolled at some point in commercial or Medicare Advantage plans from 2006 through 2017. RESULTS: We identified 27,227 unique transgender people overall; 18,785 (69%) were identified using GID codes alone. Using Endo NOS with a transgender-related procedure code, and sex-discordant hormone therapy with either Endo NOS or transgender-related procedure code, we added 4391 (16%) and 4051 (15%) transgender people, respectively. Of the 27,227 transgender people in our cohort, 8694 (32%) were transmasculine, 3959 (15%) were transfeminine, and 14,574 (54%) could not be classified. CONCLUSION: In the absence of gender identity data, additional data elements beyond GID codes improves the identification of transgender people in large, administrative claims databases.

Total cost of surgical site infection in the two years following primary knee replacement surgery.

OBJECTIVE: The disease burden of surgical site infection (SSI) following total knee (TKA) replacement is considerable and is expected to grow with increased demand for the procedure. Diagnosing and treating SSI utilizes both inpatient and outpatient services, and the timing of diagnosis can affect health service requirements. The purpose of this study was to estimate the health system costs of infection and to compare them across time-to-diagnosis categories. METHODS: Administrative data from 2005-2016 were used to identify cases diagnosed with SSI up to 1 year following primary TKA. Uninfected controls were selected matched on age, sex and comorbidities. Costs and utilization were measured over the 2-year period following surgery using hospital and out-of-hospital data. Costs and utilization were compared for those diagnosed within 30, 90, 180, and 365 days. A subsample of cases and controls without comorbidities were also compared. RESULTS: We identified 238 SSI cases over the study period. On average, SSI cases cost 8 times more than noninfected controls over the 2-year follow-up period (CaD$41,938 [US$29,965] vs CaD$5,158 [US$3,685]) for a net difference of CaD$36,780 (US$26,279). The case-to-control ratio for costs was lowest for those diagnosed within 30 days compared to those diagnosed later. When only patients without comorbidities were included, costs were >7 times higher. CONCLUSION: Our results suggest that considerable costs result from SSI following TKA and that those costs vary depending on the time of diagnosis. A 2-year follow-up period provided a more complete estimate of cost and utilization.

Placing Antismoking Graphic Warning Posters at Retail Point-of-Sale Locations Increases Some Adolescents' Susceptibility to Future Smoking.

Objectives: This experiment tested whether introducing graphic antitobacco posters at point-of-sale (POS) had any effect on adolescents' susceptibility to future cigarette smoking and whether these effects were moderated by adolescents' baseline risk of cigarette smoking. Methods: The study was conducted in the RAND StoreLab, a life-sized replica of a convenience store that was developed to experimentally evaluate how changing aspects of tobacco advertising displays in retail POS environments influence tobacco use risk and behavior during simulated shopping experiences. In this study, 441 adolescents were randomized to one of the four conditions in a 2 (graphic antismoking poster placed near the tobacco power wall: no, yes) × 2 (graphic antismoking poster placed near the cash register: no, yes) experimental design. The outcome of interest was susceptibility to future cigarette smoking. Results: The addition of antismoking posters at POS led to a significant increase in future smoking susceptibility among those adolescents who already were at high risk for smoking in the future (p < .045). The introduction of graphic antismoking posters had no impact on committed never smokers, regardless of poster location; never smokers' susceptibility to future smoking was uniformly low across experimental conditions. Conclusions: Introducing graphic antismoking posters at POS may have the unintended effect of further increasing cigarette smoking susceptibility among adolescents already at risk.

The prognostic value of pain catastrophizing in health-related quality of life judgments after Total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a highly effective procedure that yields reductions in pain and disability associated with end stage osteoarthritis (OA) of the knee. Quality of life instruments are frequently used to gauge the outcomes of total knee arthroplasty (TKA). However, research suggests that post-TKA reductions in symptom severity may not be the sole predictors of quality of life post-TKA. The primary objective of the present study was to examine the prognostic value of catastrophic thinking in health-related quality of life (HRQoL) judgments in patients with severe OA after TKA. METHODS: In this study we used a prospective cohort design to examine the value of pain catastrophizing in predicting HRQoL 1 year after TKA. Participants with advanced OA of the knee who were scheduled for TKA were recruited at one of three hospitals in Canada. The study sample consisted of 116 individuals (71 women, 45 men) who completed study questionnaires at their pre-surgical evaluation and 1 year after surgery. Hierarchical regression analysis was used to assess the unique contribution of pre-surgical pain catastrophizing to the prediction of post-surgical HRQoL judgments. RESULTS: The results of the hierarchical regression equation revealed that the overall model was significant, F (9,106) = 8.3, p < 001, and accounted for 36.4% of the variance in the prediction of post-surgical physical component score of HRQoL. Pain catastrophizing was entered in the last step of the equation and contributed significant unique variance (ß = -.35, p < .001) to the prediction of post-surgical physical component score of HRQoL above and beyond the variance accounted for by demographic variables, co-morbid health conditions, baseline HRQoL, and post-surgical reductions in pain, joint stiffness and physical disability. CONCLUSIONS: The current findings highlight the importance of pre-surgical catastrophic cognitions in influencing HRQoL judgments after TKA. The findings suggest that psychosocial interventions designed to reduce pain catastrophizing before TKA might contribute to better quality of life outcomes following surgery.

Unmet Mental Health Treatment Need and Attitudes Toward Online Mental Health Services Among Community College Students.

OBJECTIVE: A survey assessed use of and attitudes toward online mental health services among community college students to inform how such services may contribute to reducing unmet treatment need. METHODS: A total of 6,034 students completed a Web-based survey on mental health and use of and attitudes toward mental health services. Logistic regression assessed the relationship between prior mental health treatment and attitudes among students with current serious psychological distress. RESULTS: Among students with psychological distress (N=1,557), 28% reported prior in-person service use and 3% reported online mental health services use; most (60%) reported willingness to use online services. Students with no prior in-person treatment were less likely than those with history of in-person treatment to endorse preferences for in-person services (adjusted odds ratio=.54). CONCLUSIONS: Students reported being open to using online mental health services, but utilization was low. Targeted outreach efforts may be required if these services are to reduce unmet treatment need.

Ethnic Differences in Cigarette Use Trajectories and Health, Psychosocial, and Academic Outcomes.

PURPOSE: Cigarette smoking among youth is associated with poorer health and psychosocial outcomes. However, few studies address how smoking may differentially relate to the emergence of disparities in functioning across races/ethnicities over adolescence. METHODS: Youth (n = 2,509) were surveyed eight times from ages 11 to 18. We measured cigarette use, academic and social functioning, mental and physical health, and delinquency. Sequelae of change models controlled for sociodemographic factors, and tested whether intercept and slope for smoking trajectories were associated with outcomes at the end of high school, and examined racial/ethnic differences in outcomes assuming similar smoking trajectories across groups. RESULTS: Youth were 45% Hispanic, 20% Asian, 20% white, 10% multiethnic, 2% black, and 1% other ethnicities. Higher average probability of smoking and steeper slopes of smoking trajectories were associated with poorer outcomes in multiple domains. Controlling for smoking trajectories, we observed the following disparities (vs. white youth; all p's < .05): black, Hispanic, and multiethnic youth reported lower academic performance; Asian, black, and multiethnic youth reported higher academic unpreparedness; Asian and multiethnic youth reported poorer mental health; Asian, Hispanic, and multiethnic youth reported poorer physical health; and Asian youth reported higher delinquency and poorer social functioning. CONCLUSIONS: Statistically adjusting for similar smoking trajectories, racial/ethnic minority youth demonstrated poorer outcomes in multiple domains compared with white peers. Smoking may be a particularly robust marker for risk of negative outcomes in racial/ethnic minority youth. Screening for cigarette use and intervening on smoking and associated risk behaviors among minority youth may help reduce disparities in functioning.

Opportunities in Total Knee Arthroplasty: Worldwide Surgeons' Perspective.

INTRODUCTION: This study surveyed a group of US and international orthopaedic surgeons to prioritize areas of improvement in primary total knee arthroplasty (TKA). Specifically, we assessed surgeon responses regarding the top five areas of TKA needing improvement; which were stratified by: a) US surgeons, b) international surgeons, c) US surgeons' implant-brand-loyalty, and d) surgeons' years of experience and case volume. MATERIALS AND METHODS: Four hundred and eighteen surgeons who were board-certified, in practice for at least two years, spent 60% of their time in clinical practice, and performed a minimum of 25 lower extremity joint arthroplasties per year were surveyed. They chose the top five areas (among 17) needing improvement for TKA. Results were stratified by surgeons' location (US and international), implant-brand-loyalty, years of experience, and case volume. RESULTS: Functional outcomes was the top identified area for improvement (US 63% and international 71%), followed by brand loyalty (Company I 68%, other brand 59%, and multi-brand/no loyalty 66%), years of experience (early-career 64%, mid-career 63%, and late-career 75%) and case volume (low-volume 69%, mid-volume 60%, and high-volume 71%). Following this was costs for US surgeons (47%) and implant survivorship for international surgeons (57%). While costs were the next highest area for specific Company-loyal surgeons (57%), implant survivorship was the next highest area for the other two cohorts. Implant survivorship was the second most important area of improvement regardless of years of experience and for low- and mid-volume surgeons. CONCLUSION: Surgeons identified functional outcomes as the most important area needing improvement. Cost of implants was more important for American as compared to international surgeons.

Appropriateness for Total Joint Replacement: Perspectives of Decision-Makers.

BACKGROUND: Improving access to total joint replacement (TJR) has been a priority. Without robust mechanisms to ensure appropriateness, these procedures may be overused, incurring substantial costs. In that context, decision-makers are particularly concerned with the appropriateness of TJR. OBJECTIVE: While our previous research focused on the appropriateness of TJR from clinical and patient perspectives, this study is aimed at understanding decision-makers' perspectives. METHODS: Using a semi-structured guide, we interviewed a convenience sample of decision-makers in four Canadian provinces (Alberta, Manitoba, Nova Scotia and Quebec) between February and March 2013. For the purposes of this study, a decision-maker was defined as a manager, institutional leader or policy maker. RESULTS: Fifteen interviews were conducted with decision-makers at ministry (n = 3), regional (n = 6) and institutional levels (n = 8). Decision-makers see themselves as having a key role in the appropriateness discourse, that of optimizing resource allocation and efficient delivery of services for TJR, to improve population outcomes. CONCLUSION: The decision-makers' view of appropriateness recognizes the importance of the clinical view, but it offers a very different input into the appropriateness discourse, more closely aligned with appropriateness of setting, which refers to cost-effectiveness considerations.

Initial hospital-related cost comparison of total ankle replacement and ankle fusion with hip and knee joint replacement.

BACKGROUND: Total hip and knee arthroplasty (THA and TKA) are accessible to patients with end-stage hip and knee arthritis in most health care systems. The availability of total ankle arthroplasty (TAA) to patients with end-stage ankle arthritis is often restricted because of prosthesis cost. Ankle fusion (AF) is often offered as the only alternative. Patients should have equal access to procedures that are equivalent in total cost. We compared total costs of TAA, AF, THA, and TKA for similar cohorts in a government-funded teaching hospital. METHODS: A subset of 13 TAA and 13 AF patients were selected from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database, and 13 THA and 13 TKA patients were randomly selected from the Canadian Joint Replacement Registry. Total cost was estimated from operating room time, hospital stay, surgeon billing, and equipment used. RESULTS: Mean total cost associated with TAA was $13,500 ± 1000 and was the same as THA ($14,500 ± 1500) and TKA ($12,500 ± 1000). Mean total cost associated with AF was significantly less at $5500 ± 500. Mean operating room time was longer, but mean hospital stay was shorter for the ankle procedures compared with THA and TKA. CONCLUSION: All arthroplasties had similar total costs. Total ankle arthroplasty should not be denied based on prosthetic cost alone, as total procedure cost is equivalent to THA and TKA. We believe ankle fusion is a less expensive and preferable alternative for some patient groups.

The proximal modular neck in THA: a bridge too far: affirms.

Modular necks are a relatively new innovation in total hip arthroplasty (THA), with several companies now offering modular neck options. The proposed advantages of reduced impingement, reduced dislocation rate, and better reconstitution of leg length and offset are compelling. However, few reports in the literature address the outcomes of these devices, and those that are published at best demonstrate equivalence to conventional THA. There are numerous disadvantages to this new technology. Neck dissociation has been reported with a specific design of the modular taper. Numerous case reports exist of the fracture of titanium modular femoral necks, with 1 large series of 5000 cases reporting a fracture rate of 1.4%. Fractures occurred more frequently in heavy men (>100 kg), with the preponderance of fractures occurring around the 2-year mark. Retrieval analysis demonstrates failure of the titanium components at the Morse taper junction of the neck and femoral stem at the point of maximal tension, likely related to notch sensitivity. The additional interface of modular necks in the effective joint space has the potential to generate significant metal ions through a pitting corrosion process. Evidence exists of highly elevated serum cobalt and chromium ions in a modular junction used in large-head THA supporting these concerns. The use of particular neck geometries, such as long retroverted necks, may adversely affect the local biomechanical forces on the femoral component. The proposed mechanism is an increased lever arm leading to increased torque on stair climbing or rising from a chair. Finally, modular necks add significant costs to the implant and the health care system. On balance, based on the literature, the proximal modular neck in THA is a bridge too far.