High Risk of Readmission After THA Regardless of Functional Status in Patients Discharged to Skilled Nursing Facility.

BACKGROUND: The postoperative period and subsequent discharge planning are critical in our continued efforts to decrease the risk of complications after THA. Patients discharged to skilled nursing facilities (SNFs) have consistently exhibited higher readmission rates compared with those discharged to home healthcare. This elevated risk has been attributed to several factors but whether readmission is associated with patient functional status is not known. QUESTIONS/PURPOSES: After controlling for relevant confounding variables (functional status, age, gender, caregiver support available at home, diagnosis [osteoarthritis (OA) versus non-OA], Charlson comorbidity index [CCI], the Area Deprivation Index [ADI], and insurance), are the odds of 30- and 90-day hospital readmission greater among patients initially discharged to SNFs than among those treated with home healthcare after THA? METHODS: This was a retrospective, comparative study of patients undergoing THA at any of 11 hospitals in a single, large, academic healthcare system between 2017 and 2022 who were discharged to an SNF or home healthcare. During this period, 13,262 patients were included. Patients discharged to SNFs were older (73 ± 11 years versus 65 ± 11 years; p < 0.001), less independent at hospital discharge (6-click score: 16 ± 3.2 versus 22 ± 2.3; p < 0.001), more were women (71% [1279 of 1796] versus 56% [6447 of 11,466]; p < 0.001), insured by Medicare (83% [1497 of 1796] versus 52% [5974 of 11,466]; p < 0.001), living in areas with greater deprivation (30% [533 of 1796] versus 19% [2229 of 11,466]; p < 0.001), and had less assistance available from at-home caregivers (29% [527 of 1796] versus 57% [6484 of 11,466]; p < 0.001). The primary outcomes assessed in this study were 30- and 90-day hospital readmissions. Although the system automatically flags readmissions occurring within 90 days at the various facilities in the overall healthcare system, readmissions occurring outside the system would not be captured. Therefore, we were not able to account for potential differential rates of readmission to external healthcare systems between the groups. However, given the large size and broad geographic coverage of the healthcare system analyzed, we expect the readmissions data captured to be representative of the study population. The focus on a single healthcare system also ensures consistency in readmission identification and reporting across subjects. We evaluated the association between discharge disposition (home healthcare versus SNF) and readmission. Covariates evaluated included age, gender, primary payer, primary diagnosis, CCI, ADI, the availability of at-home caregivers for the patient, and the Activity Measure for Post-Acute Care (AM-PAC) 6-clicks basic mobility score in the hospital. The adjusted relative risk (ARR) of readmission within 30 and 90 days of discharge to SNF (versus home healthcare) was estimated using modified Poisson regression models. RESULTS: After adjusting for the 6-clicks mobility score, age, gender, ADI, OA versus non-OA, living environment, CCI, and insurance, patients discharged to an SNF were more likely to be readmitted within 30 and 90 days compared with home healthcare after THA (ARR 1.46 [95% CI 1.01 to 2.13]; p= 0.046 and ARR 1.57 [95% CI 1.23 to 2.01]; p < 0.001, respectively). CONCLUSION: Patients discharged to SNFs after THA had a slightly higher likelihood of hospital readmission within 30 and 90 days compared with those discharged with home healthcare. This difference persisted even after adjusting for relevant factors like functional status, home support, and social determinants of health. These results indicate that for suitable patients, direct home discharge may be a safer and more cost-effective option than SNFs. Clinicians should carefully consider these risks and benefits when making postoperative discharge plans. Policymakers could consider incentives and reforms to improve care transitions and coordination across settings. Further research using robust methods is needed to clarify the reasons for higher SNF readmission rates. Detailed analysis of patient complexity, care processes, and causes of readmission in SNFs versus home health could identify areas for quality improvement. Prospective cohorts or randomized trials would allow stronger conclusions about cause-and-effect. Importantly, no patients should be unfairly "cherry-picked" or "lemon-dropped" based only on readmission risk scores. With proper support and care coordination, even complex patients can have good outcomes. The goal should be providing excellent rehabilitation for all, while continuously improving quality, safety, and value across settings. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Drives the Material Costs of Total Knee Arthroplasty in the Operating Room?

INTRODUCTION: Approximately one-third of US healthcare spending is related to surgical care. Optimizing operating room (OR) spending is crucial, specifically for high-volume procedures like total knee arthroplasty (TKA). Therefore, the primary objective was to identify leading material drivers of cost for TKA procedures within the OR. MATERIALS AND METHODS: Patients who underwent a primary, elective TKA from 2018 to 2019 were included (n=8,672). Intraoperative cost details for each TKA patient were captured from the Vizient Clinical Database Resource Manager (CDB/RM) data. Each cost type was categorized into (1) implant, (2) disposables, (3) wound care, and (4) miscellaneous. RESULTS: 7,124 patients undergoing primary TKA were included. Implant-related costs accounted for 87.3% of cost, disposable materials covered 10.7%, and wound care products took 2%. The leading subcategories of implant costs were primary prosthetics (85.1%), revision prosthetics (9.9%), cement (2.8%), and implant instruments (1.7%). Within disposables, surgical products accounted for 81.3% of the cost, patient care products for 8.9%, medical apparel for 7.9%, and electrolytes for 1.8%. For an average individual TKA procedure, 86.4% (±4.4) of total cost went towards the implant, 10.7% (±3.4) towards disposable materials, and 1.6% (±1.4) to wound care products. Within the implant category, 92.5% (± 12.8) of costs were associated with primary implants, 13.3% (± 6.9) with instruments, and 2.5% (± 2.8) with cement. CONCLUSIONS: The primary operative material expense category was costs associated with the TKA prosthesis and its fixation followed by disposable materials. A large amount of variation exists in the percent of the total cost for a given TKA procedure that can be attributed to each category.

Considering Mobility Status and Home Environment in Readmission Risk After Total Knee Arthroplasty.

BACKGROUND: Discharge disposition following total knee arthroplasty (TKA) offers varying levels of post-acute care monitoring depending on the medical status of the patient and his or her ability to function independently. Discharge disposition following TKA is associated with 30-day and 90-day hospital readmission, but prior studies have not consistently considered confounding due to mobility status after TKA, available caregiver support, and measures of home area deprivation. The purpose of this study was to examine 30-day and 90-day readmission risk for patients discharged to a skilled nursing facility (SNF) following TKA after controlling specifically for these factors, among other covariates. METHODS: This was a retrospective cohort study of patients undergoing TKA at any of 11 hospitals in a single, large, academic health-care system between January 2, 2017, and August 31, 2022, who were discharged to an SNF or home health care (HHC). The adjusted relative risk of readmission within 30 and 90 days of discharge to an SNF compared with HHC was estimated using modified Poisson regression models. RESULTS: There were 15,212 patients discharged to HHC and 1,721 patients discharged to SNFs. Readmission within 30 days was 7.1% among patients discharged to SNFs and 2.4% among patients discharged to HHC; readmission within 90 days was 12.1% for the SNF group and 4.8% for the HHC group. The adjusted relative risk after discharge to an SNF was 1.07 (95% confidence interval [CI], 0.79 to 1.46; p = 0.65) for 30-day readmission and 1.45 (95% CI, 1.16 to 1.82; p < 0.01) for 90-day readmission. CONCLUSIONS: Discharge to an SNF compared with HHC was independently associated with 90-day readmission, but not with 30-day readmission, after controlling for mobility status after TKA, available caregiver support, and home Area Deprivation Index, among other covariates. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

A Call to Action for Musculoskeletal Research Funding: The Growing Economic and Disease Burden of Musculoskeletal Conditions in the United States Is Not Reflected in Musculoskeletal Research Funding.

ABSTRACT: As a result of an aging population, musculoskeletal disease is a growing source of health and economic burden in the United States. In 2019, musculoskeletal conditions affected approximately 127.4 million people (more than a third of the U.S. population); they were the top driver of health-care spending in 2016, with an estimated direct annual cost of $380.9 billion. While musculoskeletal conditions represent a substantial and growing burden in terms of prevalence, disability, and health-care costs, National Institutes of Health (NIH) research funding has remained disproportionately allocated to other disease conditions. Therefore, our purpose was to provide an assessment of the current burden of musculoskeletal disease in terms of prevalence, disability, and health-care costs, and compare the changing burden of disease to trends in NIH funding.

Simultaneous bilateral total knee arthroplasty has higher in-hospital complications than both staged surgeries: a nationwide propensity score matched analysis of 38,764 cases.

PURPOSE: To investigate (1) healthcare utilization, (2) in-hospital metrics and (3) total in-hospital costs associated with simultaneous versus staged BTKA while evaluating staged BTKA as a single process consisting of two combined episodes. METHODS: The national readmissions database was reviewed for simultaneous and staged (two primary unilateral TKAs12 months apart) BTKA patients (2016-2017). A total of 19,382 simultaneous BTKAs were identified, and propensity score matched (1:1) to staged BTKA patients (19,382 patients; 38,764 surgeries) based on demographics, comorbidities, and socioeconomic determinants. Outcomes included healthcare utilization [length of stay (LOS) and discharge disposition], in-hospital periprosthetic fractures, non-mechanical complications, and costs. Staged BTKA was evaluated as one process consisting of two episodes. For each staged patient, continuous outcomes were evaluated via the sum of both episodes. Categorical outcomes were added, and percents were expressed relative to total number of surgeries (n = 38,764). RESULTS: Simultaneous BTKA had longer LOS (5.0 days ± 4.7 vs. 4.5 days ± 3.5; p < 0.001), higher non-home discharge [36.9% (n = 7150/19,382) vs. 13.6% (n = 5451/38,764)], in-hospital periprosthetic fractures [0.13% (26/19,382) vs. 0.08% (31/38,764); p = 0.049], any non-mechanical complication [33.76% (6543/19,382) vs.15.93% (6177/38,764); p < 0.0001], hematoma/seroma formation [0.11% (22/19,382) vs. 0.05% (20/38,764); p = 0.0088], wound disruption [0.08% (16/19,382) vs. 0.04% (16/38,764); p = 0.0454], and any infection [1.13% (219/19,382) vs. 0.50% (194/38,764); p < 0.0001]. Average in-hospital costs for the two staged BTKA episodes combined were $5006 higher than those of simultaneous BTKA ($28,196 ± $18,488 vs. $33,202 ± $15,240; p < 0.001). CONCLUSION: Simultaneous BTKA had higher healthcare utilization and in-hospital complications than both episodes of staged BTKA combined, with a minimal in-hospital cost savings. Future studies are warranted to further explore patient selection who would benefit from BTKA.

Racial Disparities in Outcomes After THA and TKA Are Substantially Mediated by Socioeconomic Disadvantage Both in Black and White Patients.

BACKGROUND: Demographic factors have been implicated in THA and TKA outcome disparities. Specifically, patients' racial backgrounds have been reported to influence outcomes after surgery, including length of stay, discharge disposition, and inpatient readmissions. However, in the United States, health-impacting socioeconomic disadvantage is sometimes associated with racial differences in ways that can result in important confounding, thereby raising the question of whether race-associated post-THA/TKA adverse outcomes are an independent function of race or a byproduct of confounding from socioeconomic deprivation, which is potentially addressable. To explore this, we used the Area Deprivation Index (ADI) as a proxy for socioeconomic disadvantage, since it is a socioeconomic parameter that estimates the likely deprivation associated with a patient's home address. QUESTIONS/PURPOSES: The goal of this study was to investigate (1) whether race (in this study, Black versus White) was independently associated with adverse outcomes, including prolonged length of stay (LOS > 3 days), nonhome discharge, 90-day readmission, and emergency department (ED) visits while controlling for age, gender, BMI, smoking, Charlson comorbidity index (CCI), and insurance; and (2) whether socioeconomic disadvantage, measured by ADI, substantially mediated any association between race and any of the aforementioned measured outcomes. METHODS: Between November 2018 and December 2019, 2638 underwent elective primary THA and 4915 patients underwent elective primary TKA for osteoarthritis at one of seven hospitals within a single academic center. Overall, 12% (742 of 5948) of patients were Black and 88% (5206 of 5948) were White. We included patients with complete demographic data, ADI data, and who were of Black or White race; with these criteria, 11% (293 of 2638) were excluded in the THA group, and 27% (1312 of 4915) of patients were excluded in the TKA group. In this retrospective, comparative study, patient follow-up was obtained using a longitudinally maintained database, leaving 89% (2345 of 2638) and 73% (3603 of 4915) for analysis in the THA and TKA groups, respectively. For both THA and TKA, Black patients had higher ADI scores, slightly higher BMIs, and were more likely to be current smokers at baseline. Furthermore, within the TKA cohort there was a higher proportion of Black women compared with White women. Multivariable regression analysis was utilized to assess associations between race and LOS of 3 or more days, nonhome discharge disposition, 90-day inpatient readmission, and 90-day ED admission, while adjusting for age, gender, BMI, smoking, CCI, and insurance. This was followed by a mediation analysis that explored whether the association between race (the independent variable) and measured outcomes (the dependent variables) could be partially or completely attributable to confounding from the ADI (the mediator, in this model). The mediation effect was measured as a percentage of the total effect of race on the outcomes of interest that was mediated by ADI. RESULTS: In the THA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.43 [95% confidence interval (CI) 0.31 to 0.59]; p < 0.001) and nonhome discharge (OR 0.39 [95% CI 0.27 to 0.56]; p < 0.001). In mediation analysis, ADI partially explained (or mediated) 37% of the association between race and LOS of 3 days or more (-0.043 [95% CI -0.063 to -0.026]; p < 0.001) and 40% of the association between race and nonhome discharge (0.041 [95% CI 0.024 to 0.059]; p < 0.001). However, a smaller direct association between race and both outcomes was observed (LOS 3 days or more: -0.075 [95% CI -0.13 to -0.024]; p = 0.004; nonhome discharge: 0.060 [95% CI 0.016 to 0.11]; p = 0.004). No association was observed between race and 90-day readmission or ED admission in the THA group. In the TKA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.41 [95% CI 0.32 to 0.54]; p < 0.001), nonhome discharge (OR 0.44 [95% CI 0.33 to 0.60]; p < 0.001), 90-day readmission (OR 0.54 [95% CI 0.39 to 0.77]; p < 0.001), and 90-day ED admission (OR 0.60 [95% CI 0.45 to 0.79]; p < 0.001). In mediation analysis, ADI mediated 19% of the association between race and LOS of 3 days or more (-0.021 [95% CI -0.035 to -0.007]; p = 0.004) and 38% of the association between race and nonhome discharge (0.029 [95% CI -0.016 to 0.040]; p < 0.001), but there was also a direct association between race and these outcomes (LOS 3 days or more: -0.088 [95% CI -0.13 to -0.049]; p < 0.001; nonhome discharge: 0.046 [95% CI 0.014 to 0.078]; p = 0.006). ADI did not mediate the associations observed between race and 90-day readmission and ED admission in the TKA group. CONCLUSION: Our findings suggest that socioeconomic disadvantage may be implicated in a substantial proportion of the previously assumed race-driven disparity in healthcare utilization parameters after primary total joint arthroplasty. Orthopaedic surgeons should attempt to identify potentially modifiable socioeconomic disadvantage indicators. This serves as a call to action for the orthopaedic community to consider specific interventions to support patients from vulnerable areas or whose incomes are lower, such as supporting applications for nonemergent medical transportation or referring patients to local care coordination agencies. Future studies should seek to identify which specific resources or approaches improve outcomes after TJA in patients with socioeconomic disadvantage. LEVEL OF EVIDENCE: Level III, therapeutic study.

Staged Versus Simultaneous Bilateral Knee Arthroplasty: Does Minimal Cost Difference Justify Risks?

BACKGROUND: Simultaneous bilateral total knee arthroplasty (BTKA) is associated with a higher risk but can be perceived to afford faster improvement and mitigated costs versus staged BTKA. We aimed to explore (1) health care utilization, (2) surgical supply costs of simultaneous BTKA; and (3) 1-year improvement in patient-reported pain, function, and quality of life (QOL) versus staged BTKA. METHODS: A prospective cohort of 198 simultaneous and 625 staged BTKAs was obtained (2016-2020). Simultaneous BTKA cohort was propensity score-matched (1:2) to a similar group of staged patients (simultaneous = 198 versus staged = 396). Outcomes included length of stay, discharge disposition, 90-day readmission, 1-year reoperation, surgical episode supply cost, Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain, KOOS-Physical Function Short Form, and KOOS-QOL. Rates of attaining minimal clinically important difference and Patient Acceptable Symptomatic State were calculated. RESULTS: Compared to both staged BTKA surgeries combined, simultaneous BTKA demonstrated shorter median net length of stay (2.00 [2.00, 3.00] days versus 2.00 [2.00, 4.00] days; P < .001) but higher rates of nonhome discharge (n = 56 [28.3%] versus n = 32 [4.04%]; P < .001), 90-day readmission (n = 20 [10.1%] versus n = 48 [6.06%]; P = .047) and similar reoperation rates (P = .44). Simultaneous BTKA afforded slight reduction in net surgical cost compared to that of both staged BTKAs combined ($643; P = .028). There was no significant difference in 1-year improvement and minimal clinically important difference attainment rates with simultaneous versus staged BTKA for KOOS-pain (P = .137 and P = .99), KOOS-QOL (P = .095 and P = .81), or KOOS-Physical Function Short Form (P = .75 and P = .49, respectively) or Patient Acceptable Symptomatic State (P = .12). CONCLUSION: Staged BTKA is associated with similar 1-year pain, function, and QOL at a better safety profile and minimal surgical supply cost increase compared to simultaneous BTKA.

Team Approach: Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty.

¼: Nutritional assessment is a critical element of routine preoperative assessment and should be approached by an interdisciplinary team that involves the primary care physician, dietitian, and orthopaedist. ¼: Patients should be stratified on the basis of their nutritional risk, which influences downstream optimization and deficiency reversal. ¼: The scientific literature indicates that nutritional supplementation affords protection against adverse outcomes and helps functional recovery, even among patients who are not at nutritional risk. ¼: Published investigations recommend a sufficient preoperative interval (at least 4 weeks) to ensure an adequate nutritional intervention in malnourished patients as opposed to regarding them as nonsurgical candidates.

Neighborhood Socioeconomic Disadvantages Associated With Prolonged Lengths of Stay, Nonhome Discharges, and 90-Day Readmissions After Total Knee Arthroplasty.

BACKGROUND: Low socioeconomic status and neighborhood context has been linked to poor health care outcomes after total knee arthroplasty (TKA). The area deprivation index (ADI) addresses this relationship by ranking neighborhoods by socioeconomic disadvantage. We examined the following relationships of the ADI among TKA recipients: (1) patient demographics, (2) lengths of stay (LOS), (3) nonhome discharges, and (4) 90-day readmissions, emergency department visits, and reoperations. METHODS: We reviewed a consecutive series of primary TKAs from 2018 through 2020 at a tertiary health care system. A total of 3928 patients who had complete ADI data were included. A plurality of patients (14.9%) were categorized within ADI 31-40, below the national median ADI of 47. Associations between the national ADI decile and 90-day postoperative health care utilization metrics were evaluated using multivariate regressions (adjusted for patient demographics and comorbidities). RESULTS: The 91-100 ADI cohort was disproportionately African American, female, younger, and smokers. Compared with ADI 31-40 (reference), the ADI 61-70 cohort was associated with higher odds of LOS ≥3 days (odds ratio [OR] = 1.6 [1.08-2.36], P = .019) and nonhome discharges (OR = 1.73 [1.08-2.75], P = .021). The ADI 91-100 cohort was associated with the highest odds of prolonged LOS (OR = 2.27; [1.47-3.49], P < .001), nonhome discharges (OR = 3.49 [2.11-5.78], P < .001), and all-cause readmissions (OR: 1.79, [1.02-3.14], P = .044). No significant associations were found between the ADI and 90-day emergency department visits or reoperations (P > .05). CONCLUSION: A higher ADI was associated with prolonged LOS, nonhome discharge status, and 90-day readmissions after TKA. This index highlights potential areas of intervention for assessing health care outcomes.

NarxCare Scores Greater Than 300 Are Associated with Adverse Outcomes After Primary THA.

BACKGROUND: The association between preoperative prescription drug use (narcotics, sedatives, and stimulants) and complications and/or greater healthcare utilization (length of stay, discharge disposition, readmission, emergency department visits, and reoperation) after total joint arthroplasty has been established but not well quantified. The NarxCare score (NCS) is a weighted scalar measure of overall prescription opioid, sedative, and stimulant use. Higher scores reflect riskier drug-use patterns, which are calculated based on (1) the number of prescribing providers, (2) the number of dispensing pharmacies, (3) milligram equivalence doses, (4) coprescribed potentiating drugs, and (5) overlapping prescription days. The aforementioned factors have not been incorporated into association measures between preoperative prescription drug use and adverse events after THA. In addition, the utility of the NCS as a scalar measure in predicting post-THA complications has not been explored. QUESTIONS/PURPOSES: (1) Is the NarxCare score (NCS) associated with 90-day readmission, reoperation, emergency department visits, length of stay, and discharge disposition after primary THA; and are there NCS thresholds associated with a higher risk for those adverse outcomes if such an association exists? (2) Is there an association between the type of preoperative active drug prescription and the aforementioned outcomes? METHODS: Of 3040 primary unilateral THAs performed between November 2018 and December 2019, 92% (2787) had complete baseline information and were subsequently included. The cohort with missing baseline information (NCS or demographic/racial determinants; 8%) had similar BMI distribution but slightly younger age and a lower Charlson Comorbidity Index (CCI). Outcomes in this retrospective study of a longitudinally maintained institutional database included 90-day readmissions (all-cause, procedure, and nonprocedure-related), reoperations, 90-day emergency department (ED) visits, prolonged length of stay (> 2 days), and discharge disposition (home or nonhome). The association between the NCS category and THA outcomes was analyzed through multivariable regression analyses and a confirmatory propensity score-matched comparison based on age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, which removed significant differences at baseline. A similar regression model was constructed to evaluate the association between the type of preoperative active drug prescription (opioids, sedatives, and stimulants) and adverse outcomes after THA. RESULTS: After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, an NCS of 300 to 399 was associated with a higher odds of 90-day all-cause readmission (odds ratio 2.0 [95% confidence interval 1.1 to 3.3]; p = 0.02), procedure-related readmission (OR 3.3 [95% CI 1.4 to 7.9]; p = 0.006), length of stay > 2 days (OR 2.2 [95% CI 1.5 to 3.2]; p < 0.001), and nonhome discharge (OR 2.0 [95% CI 1.3 to 3.1]; p = 0.002). A score of 400 to 499 demonstrated a similar pattern, in addition to a higher odds of 90-day emergency department visits (OR 2.2 [95% CI 1.2 to 3.9]; p = 0.01). After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, we found no clinically important association between an active opioid prescription and 90-day all-cause readmission (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.05), procedure-related readmission (OR 1.003 [95% CI 1.001 to 1.006]; p = 0.02), length of stay > 2 days (OR 1.003 [95% CI 1.002 to 1.005]; p < 0.001), or nonhome discharge (OR 1.002 [95% CI 1.001 to 1.003]; p = 0.019); the large size of the database allowed us to find statistical associations, but the effect sizes are so small that the finding is unlikely to be clinically meaningful. A similarly small association that is unlikely to be clinically important was found between active sedative use and 90-day ED visits (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.02). CONCLUSION: Preoperative prescription drug use, as reflected by higher NCSs, has a dose-response association with adverse outcomes after THA. Surgeons may use the preoperative NCS to initiate and guide a patient-centered discussion regarding possible postoperative risks associated with prescription drug-use patterns (sedatives, opioids, or stimulants). An interdisciplinary approach can then be initiated to mitigate unfavorable patterns of prescription drug use and subsequently lower patient NCSs. However, given its nature and its reflection of drug-use patterns rather than patients' current health status, the NCS does not qualify as a basis for surgical denial or ineligibility. LEVEL OF EVIDENCE: Level III, diagnostic study.

A Call for Improved Screening of Preoperative Prescription Drug Abuse: A Scalar Assessment Not Limited to Opioids.

Prescription-drug abuse has strained US healthcare. While several investigations highlight an association between opioid use and adverse postoperative outcomes, similar associations with nonopioid prescription-drugs remain under-studied. Furthermore, patients' underlying prescription drug use patterns remain poorly characterized. This perspective details such obstacles which hinder translating literature-reported findings into practice.

Hospital Volume and Postoperative Infections in Total Knee Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the associations of hospital volume with revision surgery for infection and superficial incisional infections. METHODS: A review of 12,541 primary total knee arthroplasties (TKAs) at a large integrated health system from 2014 to 2017 was conducted. Sixteen hospitals were classified as low-volume, medium-volume, or high-volume hospitals according to the mean number of TKAs/year (<250, 250-500, and >500, respectively). Thresholds were guided by percentiles and the literature on volume-outcome relationships. Medical records were reviewed for revision surgery for infection and superficial incisional infections during a mean 2-year review period. Multivariate analyses, adjusted for clinical and patient characteristics, were performed to evaluate the association between hospital volume and infection. RESULTS: The overall rate of revision surgery for infection was 0.7% (n = 82), and the overall rate of superficial incisional infection was 2.6% (n = 324). After accounting for potential confounders, hospital volume was not found to have a significant association with revision surgery for infection when comparing high-volume and low-volume hospitals (odds ratio, 1.615; 95% confidence interval, 0.761-3.427; P = .212) as well as when comparing high-volume and medium-volume hospitals (odds ratio, 1.464; 95% confidence interval, 0.853-2.512; P = .166). Moreover, the risk of superficial incisional infection at high-volume hospitals was similar to that at low-volume (P = .107) and medium-volume (P = .491) hospitals. CONCLUSION: Infection outcomes are quality metrics that are frequently used to compare hospitals including those of varying volumes. Using contemporary thresholds, this study found that infection rates after TKA at high-volume hospitals are comparable to low-volume and medium-volume hospitals.

Hematologic Malignancies Are Associated with Adverse Perioperative Outcomes following Total Knee Arthroplasty.

The treatment of hematologic malignancies has advanced over the years, resulting in an improved survival of patients. As a result, these patients may be a part of the increasing population requiring total knee arthroplasty (TKA); however, they might be at a higher risk of adverse perioperative outcomes. The purpose of this study was to determine the perioperative outcomes (complications, length of stay [LOS], and costs) of patients with hematologic malignancies following TKA. This study used the Nationwide Inpatient Sample (NIS) to identify patients who underwent TKA in the United States from 2000 to 2011. Patients diagnosed with any hematologic malignancy (N = 24,714) were then stratified by Hodgkin's disease (N = 791), Non-Hodgkin's lymphoma (N = 7,096), plasma cell dyscrasias (N = 1,621), leukemia (N = 8,005), myeloproliferative disease (N = 5,746), and/or myelodysplastic syndromes (N = 1,608) for determining the complications that occurred during admission. Propensity matching was performed for demographics, hospital characteristics, and comorbidities, which yielded 24,491 patients with any hematologic malignancy and 24,458 control patients. Additionally, propensity matching was performed for the hematologic malignancy subtypes. Multivariable regression models were used to analyze the surgical and medical complications, LOS, and costs. The annual frequency of THA in patients with any hematologic malignancy increased from 2000 to 2011 (p < 0.0001). Hematologic malignancies were associated with an increased risk of any surgery-related complication (odds ratio [OR] = 1.31, p < 0.0001) and any general medical complication (OR = 1.38, p < 0.0001). Patients with any hematologic malignancy had increased odds of complications, including acute postoperative anemia (OR = 1.29, p < 0.0001), hematoma/seroma (OR = 1.65, p < 0.02), peripheral vascular disease (OR = 2.23, p = 0.046), deep venous thrombosis (DVT) (OR = 1.95, p = 0.02), and blood transfusion (OR = 1.61, p < 0.0001). Hematologic malignancies were associated with an increased incremental LOS (0.13 d, p < 0.0001) and an increased incremental cost ($788, p < 0.0001). Thus, we conclude that following TKA, patients with hematologic malignancies are at an increased risk of perioperative complications, longer LOS, and higher costs. The risk quantification for adverse perioperative outcomes in association with an increased cost may help design different risk stratification and reimbursement methods in such patients when undergoing TKA.

Readmission, Reoperation, and Complications: Total Hip vs Total Knee Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are currently grouped under the same Diagnosis-Related Group (DRG). With the introduction of bundled payments, providers are accountable for all the costs incurred during the episode of care, including the costs of readmissions and management of complications. However, it is unclear whether readmission rates and short-term complications are similar in primary THA and TKA. METHODS: The National Surgical Quality Improvement Project database was queried from 2011 to 2015 to identify 248,150 primary THA/TKA procedures using Current Procedural Terminology codes. After excluding 1602 hip fractures and 5062 bilateral procedures, 94,326 THAs and 147,160 TKAs were included in the study. Length of stay, discharge disposition, and 30-day readmission, reoperation and complication rates were compared between THA and TKA using multivariate regression models. RESULTS: After adjusting for baseline characteristics, length of stay (P = .055) and discharge disposition (P = .304) were similar between THA and TKA. But the 30-day rates of readmission (P < .001) and reoperation (P < .001) were higher in THA. Of the 18 complications evaluated in the study, 7 were higher in THA, 3 were higher in TKA, and 8 were similar between THA and TKA. CONCLUSION: THA patients had higher 30-day rates of readmission and reoperation. As both readmissions and reoperations can result in higher episode costs, a common target price for both THA and TKA may be inappropriate. Further studies are required to fully understand the extent of differences in the episode costs of THA and TKA.

Older Adults Undergoing Total Hip or Knee Arthroplasty: Chronicling Changes in Their Multimorbidity Profile in the Last Two Decades.

BACKGROUND: Despite the ubiquitous use of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in older adults, little is known about the multimorbidity (MM) profile of this patient population. This study evaluates the temporal trends of MM, hypothesizing that patients with MM have had an increasingly greater representation in THA and TKA patients over time. METHODS: Data on a US representative sample of older adults from the linked Health and Retirement Study and Medicare data from 1993 to 2012 were used. The Health and Retirement Study is a biennial survey that collects data on a broad array of measures, including self-reported chronic conditions and geriatric syndromes, which were used to account for MM. Medicare data were used to identify fee-for-service Medicare beneficiaries who underwent THA (n = 479) or TKA (n = 998) during the study years, which were grouped into 3 periods: 1993-1999, 2000-2006, and 2007-2012. Multivariable logistic regression analysis was conducted to obtain age-, gender-, and race-adjusted time trends for MM. RESULTS: Compared to the earliest study period, and for both THA and TKA patients, there were significantly fewer patients with stroke and/or poor cognitive performance in the most recent study period. In addition, more TKA than THA patients presented with 2+ chronic conditions. Nearly 70% presented with co-occurring chronic conditions and geriatric syndromes, and this percentage did not change significantly over time. CONCLUSION: The high representation of THA and TKA patients presenting with co-occurring chronic conditions and geriatric syndromes in this patient population warrants detailed exploration of the effects of geriatric syndromes on postoperative outcomes.

Hematologic Malignancies Are Associated With Adverse Perioperative Outcomes After Total Hip Arthroplasty.

BACKGROUND: Advancements in treating hematologic malignancies have improved survival, and these patients may be part of the growing population undergoing total hip arthroplasty (THA). Therefore, the purpose of this study was to evaluate the perioperative outcomes of THA in patients with hematologic malignancies. METHODS: The Nationwide Inpatient Sample identified patients who underwent THA from 2000 to 2011 (n = 2,864,412). Patients diagnosed with any hematologic malignancy (n = 18,012) were further stratified into Hodgkin disease (n = 786), non-Hodgkin lymphoma (n = 5062), plasma cell dyscrasias (n = 2067), leukemia (n = 5644), myeloproliferative neoplasms (n = 3552), and myelodysplastic syndromes (n = 1082). Propensity matching for demographics, hospital characteristics, and comorbidities identified 17,810 patients with any hematologic malignancy and 17,888 controls; additional matching was performed to compare hematologic malignancy subtypes with controls. Multivariate regression was used to analyze surgical and medical complications, length of stay (LOS), and costs. RESULTS: Compared to controls, hematologic malignancies increased the risk of any surgery-related complication (odds ratio [OR], 1.4; P < .0001) and any general medical complication (OR, 1.47; P < .0001). Additionally, hematologic malignancies were associated with an increase in LOS (0.16 days; P = .004) and increased costs ($1,101; P < .0001). CONCLUSION: Patients with hematologic malignancies undergoing THA have an increased risk of perioperative complications, longer LOS, and higher costs. The risk quantification for adverse perioperative outcomes in association with increased cost may help to design different risk stratification and reimbursement methods in such populations.

The Impact of Solid Organ Transplant History on Inpatient Complications, Mortality, Length of Stay, and Cost for Primary Total Hip Arthroplasty Admissions in the United States.

BACKGROUND: As the prevalence of and life expectancy after solid organ transplantation increases, some of these patients will require total hip arthroplasty (THA). Immunosuppressive therapy, metabolic disorders, and post-transplant medications may place transplant patients at higher risk of adverse events following surgery. The objective of this study was to compare inpatient complications, mortality, length of stay (LOS), and costs for THA patients with and without solid organ transplant history. METHODS: A retrospective cross-sectional analysis was conducted using 1998-2011 Nationwide Inpatient Sample. Primary THA patients were queried (n = 3,175,456). After exclusions, remaining patients were assigned to transplant (n = 7558) or non-transplant groups (n = 2,772,943). After propensity score matching, adjusted for patient and hospital characteristics, logistic regression and paired t-tests examined the effect of transplant history on outcomes. RESULTS: Between 1998 and 2011, THA volume among transplant patients grew approximately 48%. The overall prevalence of one or more complications following THA was greater in the transplant group than in the non-transplant group (32.0% vs 22.1%; P < .001). In-hospital mortality was minimal, with comparable rates (0.1%) in both groups (P = .93). Unadjusted trends show that transplant patients have greater annual and overall mean LOS (4.47 days) and mean admission costs ($18,402) than non-transplant patients (3.73 days; $16,899; P < .001). After propensity score matching, transplant history was associated with increased complication risk (odds ratio, 1.56) after THA, longer hospital LOS (+0.64 days; P < .001), and increased admission costs (+$887; P = .005). CONCLUSION: Transplant patients exhibited increased odds of inpatient complications, longer LOS, and greater admission costs after THA compared with non-transplant patients.

Impact of Cirrhosis on Resource Use and Inpatient Complications in Patients Undergoing Total Knee and Hip Arthroplasty.

BACKGROUND: Cirrhosis is a major cause of morbidity and mortality and is an important risk factor for complications in surgical patients. The purpose of this study was to investigate the association of cirrhosis with postoperative complications, length of stay (LOS), and costs among patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA). METHODS: Using the Nationwide Inpatient Sample between 2000 and 2011, we identified patients who had a primary TKA or primary THA. TKA patients were divided into 2 groups: (1) cirrhosis (n = 41,464) and (2) no cirrhosis (n = 5,721,297) and THA patients were divided into 2 groups: (1) cirrhosis (n = 27,401) and (2) no cirrhosis (n = 2,622,539). Patient demographics, comorbidities, perioperative complications, LOS, and incremental costs were analyzed. An additional subgroup analysis by cirrhosis etiology was performed. RESULTS: Multivariable analysis revealed cirrhosis was associated with 1.55 (95% confidence interval: 1.47-1.63) times higher odds of any complication after TKA and 1.59 (1.50-1.69) higher odds after THA. Adjusted outcomes showed cirrhotic TKA patients had $1857 higher costs and 0.30 days longer LOS and THA cirrhotic patients had $1497 higher costs and 0.48 longer LOS. We found similar results for each cirrhosis subtype but alcohol-related had the highest resource use and complication rate. CONCLUSION: Patients with cirrhosis who are undergoing TKA or THA are at a significantly increased risk for perioperative complications, increased LOS, and higher costs. The perioperative complications and costs were highest among patients with alcohol-related cirrhosis.

Prevalence and Perioperative Outcomes of Off-Label Total Hip and Knee Arthroplasty in the United States, 2000-2010.

"Off-label use" refers to medical device utilization for purposes or subpopulations other than those approved by the United States Food and Drug Administration. The primary goal of this study was to determine the current epidemiology of off-label total hip and knee arthroplasties (THA and TKA, respectively) in the United States and to project further off-label use through 2040. Over the past decade, the prevalence of off-label THA and TKA was 30.4% and 37.0%, respectively, growing ~70% from 2000 to 2010. By 2040, the majority of THAs (86.1%) and TKAs (91.5%) could be off-label. The high prevalence of off-label arthroplasty and the dramatically shifting patient profile illustrated by these results highlight the need for continued medical device surveillance among on- and off label patients.

Early Postoperative Outcomes of Primary Total Knee Arthroplasty After Solid Organ Transplantation in the United States, 1998-2011.

This review of the Nationwide Inpatient Sample (1998-2011) examined trends in solid organ transplant patients who received a total knee arthroplasty (TKA) to determine whether length of stay (LOS), cost, and perioperative complications differed from non-transplant peers. Primary TKA patients (n=5,870,421) were categorized as: (1) those with a history of solid organ transplant (n=6104) and (2) those without (n=5,864,317). Propensity matching was used to estimate adjusted effects of solid organ transplant history on perioperative outcomes. The percentage of TKA patients with a transplant history grew during the study period from 0.069% to 0.103%. Adjusted outcomes showed patients with a transplant had a 0.44 day longer LOS, $962 higher cost of admission, and were 1.43 times more likely to suffer any complication (P=0.0002).