Assessment of Risk Factors and Rate of Conversion to Total Hip Arthroplasty Within 2 Years After Hip Arthroscopy Utilizing a Large Database of Commercially Insured Patients in the United States.

Background: The conversion rate of hip arthroscopy (HA) to total hip arthroplasty (THA) has been reported to be as high as 10%. Despite identifying factors that increase the risk of conversion, current studies do not stratify patients by type of arthroscopic procedure. Purpose/Hypothesis: To analyze the rate and predictors of conversion to THA within 2 years after HA. It was hypothesized that osteoarthritis (OA) and increased patient age would negatively affect the survivorship of HA. Study Design: Cohort study; Evidence level, 3. Methods: The IBM MarketScan database was utilized to identify patients who underwent HA and converted to THA within 2 years at inpatient and outpatient facilities between 2013 and 2017. Patients were split into 3 procedure cohorts as follows: (1) femoroacetabular osteoplasty (FAO), which included treatment for femoroacetabular impingement; (2) isolated debridement; and (3) isolated labral repair. Cohort characteristics were compared using standardized differences. Conversion rates between the 3 cohorts were compared using chi-square tests. The relationship between age and conversion was assessed using linear regression. Predictors of conversion were analyzed using multivariable logistic regression. The median time to conversion was estimated using Kaplan-Meier tests. Results: A total of 5048 patients were identified, and the rates of conversion to THA were 12.86% for isolated debridement, 8.67% for isolated labral repair, and 6.76% for FAO (standardized difference, 0.138). The isolated labral repair cohort had the shortest median time to conversion (isolated labral repair, 10.88 months; isolated debridement, 10.98 months; and FAO, 11.9 months [P = .034). For patients >50 years, isolated debridement had the highest rate of conversion at 18.8%. The conversion rate increased linearly with age. Factors that increased the odds of conversion to THA were OA, having an isolated debridement procedure, and older patient age (P < .05). Conclusion: Older patients and those with preexisting OA of the hip were at a significantly increased risk of failing HA and requiring a total hip replacement within 2 years of the index procedure. Younger patients were at low risk of requiring a conversion procedure no matter which arthroscopic procedure was performed.

Evaluating Resource Utilization for In-Person and Virtual Joint Classes in Total Joint Arthroplasty: An Analysis of Attendance Patterns at a Large Metropolitan Health System.

BACKGROUND: Provider-run "joint classes" educate total joint arthroplasty (TJA) patients on how to best prepare for surgery and maximize recovery. There is no research on potential healthcare inequities in the context of joint classes or on the impact of the recent shift toward telehealth due to coronavirus disease 2019 (COVID-19). Using data from a large metropolitan health system, we aimed to (1) identify demographic patterns in prepandemic joint class attendance and (2) understand the impact of telehealth on attendance. METHODS: We included data on 3,090 TJA patients from three centers, each with a separately operated joint class. Attendance patterns were assessed prepandemic and after the resumption of elective surgeries when classes transitioned to telehealth. Statistical testing included standardized differences (SD > 0.1 indicates significance) and a multivariate linear regression. RESULTS: The in-person and telehealth attendance rates were 69.9% and 69.2%, respectively. Joint class attendance was significantly higher for non-White, Hispanic, non-English primary language, Medicaid, and Medicare patients (all SD > 0.1). Age was a determinant of attendance for telehealth (SD > 0.1) but not for in-person (SD = 0.04). Contrastingly, physical distance from hospital was significant for in-person (SD > 0.1) but not for telehealth (SD = 0.06). On a multivariate analysis, distance from hospital (P < .05) and telehealth (P < .0001) were predictors of failed class attendance. CONCLUSION: This work highlights the relative importance of joint classes in specific subgroups of patients. Although telehealth attendance was lower, telehealth alleviated barriers to access related to physical distance but increased barriers for older patients. These results can guide providers on preoperative education and the implementation of telehealth.

Risk Factors for 30- and 90-Day Readmissions Due To Surgical Site Infection Following Posterior Lumbar Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: Identify the independent risk factors for 30- and 90-day readmission because of surgical site infection (SSI) in patients undergoing elective posterior lumbar fusion (PLF). SUMMARY OF BACKGROUND DATA: SSI is a significant cause of morbidity in the 30- and 90-day windows after hospital discharge. There remains a gap in the literature on independent risk factors for readmission because of SSI after PLF procedures. In addition, readmission for SSI after spine surgery beyond the 30-day postoperative period has not been well studied. METHODS: A retrospective analysis was performed on data from the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. The authors identified 65,121 patients who underwent PLF. There were 191 patients (0.30%) readmitted with a diagnosis of SSI in the 30-day readmission window, and 283 (0.43%) patients readmitted with a diagnosis of SSI in the 90-day window. Baseline patient demographics and medical comorbidities were assessed. Bivariate and multivariate analyses were performed to examine the independent risk factors for readmission because of SSI. RESULTS: In the 30-day window after discharge, this study identified patients with liver disease, uncomplicated diabetes, deficiency anemia, depression, psychosis, renal failure, obesity, and Medicaid or Medicare insurance as higher risk patients for unplanned readmission with a diagnosis of SSI. The study identified the same risk factors in the 90-day window with the addition of diabetes with chronic complications, chronic pulmonary disease, and pulmonary circulation disease. CONCLUSIONS: Independent risk factors for readmission because of SSI included liver disease, uncomplicated diabetes, obesity, and Medicaid insurance status. These findings suggest that additional intervention in the perioperative workup for patients with these risk factors may be necessary to lower unplanned readmission because of SSI after PLF surgery.

A Comparison of the Elixhauser and Charlson Comorbidity Indices: Predicting In-Hospital Complications Following Anterior Lumbar Interbody Fusions.

OBJECTIVE: The Elixhauser Comorbidity Index (ECI) and Charlson Comorbidity Index (CCI) are commonly used measures that use administrative data to characterize a patient's comorbidity burden. The purpose of this study was to compare the ability of these measures to predict outcomes following anterior lumbar interbody fusion. METHODS: The National Inpatient Sample was queried for all ALIF procedures between 2013 and 2014. The area under the receiver operating curve (AUC) was used to compare the ECI and CCI in their ability to predict postoperative complications when incorporated into a base model containing age, sex, race, and primary payer. Percent superiority was computed using AUC values for ECI, CCI, and base models. RESULTS: A total of 43,930 hospitalizations were included in this study. The ECI was superior to the CCI and baseline models in predicting minor (AUC 71 vs. 0.66, P < 0.0001) and major (AUC 0.74 vs. 0.67, P < 0.0001) complications. When evaluating individual complications, the ECI was superior to the CCI in predicting airway complications (65% superior, AUC 0.85 vs. 0.72, P = 0.0001); hemorrhagic anemia (83% superior, AUC 0.71 vs. 0.66, P < 0.0001); myocardial infarction (76% superior, AUC 0.86 vs. 0.67, P < 0.0001); cardiac arrest (75% superior, AUC 0.85 vs. 0.67, P < 0.0001); pulmonary embolism (105% superior, AUC 0.91 vs. 0.71, P < 0.0001); and urinary tract infection (43% superior, AUC 0.76 vs. 0.73, P = 0.046). CONCLUSIONS: The ECI was superior to the CCI in predicting 6 of the 15 complications analyzed in this study. Combined with previous results, the ECI may be a better predictive model in spine surgery.

The Seven-Year Cost-Effectiveness of Anterior Cervical Discectomy and Fusion Versus Cervical Disc Arthroplasty: A Markov Analysis.

STUDY DESIGN: Markov model analysis. OBJECTIVE: The aim of this study was to determine the 7-year cost-effectiveness of single-level anterior cervical discectomy and fusion (ACDF) versus cervical disc replacement (CDR) for the treatment of cervical disc degeneration. SUMMARY OF BACKGROUND DATA: Both ACDF and CDR are acceptable surgical options for the treatment of symptomatic cervical disc degeneration. Past studies have demonstrated at least equal effectiveness of CDR when compared with ACDF in large randomized Investigational Device Exemption (IDE) studies. Short-term cost-effectiveness analyses at 5 years have suggested that CDR may be the preferred treatment option. However, adjacent segment disease and other postoperative complications may occur after 5 years following surgery. METHODS: A Markov model analysis was used to evaluate data from the LDR Mobi-C IDE study, incorporating five Markov transition states and seven cycles with each cycle set to a length of 1 year. Transition state probabilities were determined from complication rates, as well as index and adjacent segment reoperation rates from the IDE study. Raw SF-12 data were converted to health state utility values using the SF-6D algorithm for 174 CDR patients and 79 ACDF patients. RESULTS: Assuming an ideal operative candidate who is 40-years-old and failed appropriate conservative care, the 7-year cost was $103,924 for ACDF and $105,637 for CDR. CDR resulted in the generation of 5.33 quality-adjusted life-years (QALYs), while ACDF generated 5.16 QALYs. Both ACDF and CDR were cost-effective, but the incremental cost-effectiveness ratio (ICER) was $10,076/QALY in favor of CDR, which was less than the willingness-to-pay (WTP) threshold of $50,000/QALY. CONCLUSION: ACDF and CDR are both cost-effective strategies for the treatment of cervical disc degeneration. However, CDR is the more cost-effective procedure at 7 years following surgery. Further long-term studies are needed to validate the findings of this model. LEVEL OF EVIDENCE: 1.