Narcotic prescribing practices in shoulder surgery before and after the institution of narcotic e-prescribing.

Background: Given the current opioid epidemic, it is crucial to highly regulate the prescription of narcotic medications for pain management. The use of electronic prescriptions (e-scripts) through the hospital's electronic medical record platform allows physicians to fill opioid prescriptions in smaller doses, potentially limiting the total quantity of analgesics patients have access to and decreasing the potential for substance misuse. The purpose of this study is to determine how the implementation of e-scripts changed the quantity of opioids prescribed following shoulder surgeries. Methods: For this single-center retrospective study, data were extracted for all patients aged 18 years or more who received a shoulder procedure between January 2015 and December 2020. Total milligrams of morphine equivalents (MMEs) of opioids prescribed within the 90 days following surgery were compared between 3 cohorts: preimplementation of the 2017 New Jersey Opioid laws (Pre-NJ opioid laws), post-NJ Opioid Laws but pre-escripting, and postimplementation of e-scripting in 2019 (postescripting). Any patient prescribed preoperative opioids, prescribed opioids by nonorthopedic physicians, under the care of a pain management physician, or had a simultaneous nonshoulder procedure was excluded from this study. Results: There were 1857 subjects included in this study; 796 pre-NJ opioid laws, 520 post-NJ opioid laws, pre-escripting, and 541 postescripting. Following implementation of e-scripting on July 1, 2019, there was a significant decrease in total MMEs prescribed (P < .001) from a median of 90 MME (interquartile range 65, 65-130) preimplementation to a median 45 MME (interquartile range 45, 45-90) MME postimplementation Additionally, there was a statistically significant decrease in opioids prescribed for all procedures (P < .001) and for 3 (P < .001) of the 4 orthopedic surgeons included in this study. Conclusion: Our study demonstrated a significant reduction in total MMEs prescribed overall, for all shoulder surgeries, and for the majority of our institution's providers in the postoperative period following the e-scripting implementation in July 2019. E-scripting is a valuable tool in conjunction with education and awareness on the national, institutional, provider, and patient levels to combat the opioid epidemic.

Assessment of the Dissemination of COVID-19-Related Articles Across Social Media: Altmetrics Study.

BACKGROUND: The use of social media assists in the distribution of information about COVID-19 to the general public and health professionals. Alternative-level metrics (ie, Altmetrics) is an alternative method to traditional bibliometrics that assess the extent of dissemination of a scientific article on social media platforms. OBJECTIVE: Our study objective was to characterize and compare traditional bibliometrics (citation count) with newer metrics (Altmetric Attention Score [AAS]) of the top 100 Altmetric-scored articles on COVID-19. METHODS: The top 100 articles with the highest AAS were identified using the Altmetric explorer in May 2020. AAS, journal name, and mentions from various social media platforms (Twitter, Facebook, Wikipedia, Reddit, Mendeley, and Dimension) were collected for each article. Citation counts were collected from the Scopus database. RESULTS: The median AAS and citation count were 4922.50 and 24.00, respectively. TheNew England Journal of Medicine published the most articles (18/100, 18%). Twitter was the most frequently used social media platform with 985,429 of 1,022,975 (96.3%) mentions. Positive correlations were observed between AAS and citation count (r2=0.0973; P=.002). CONCLUSIONS: Our research characterized the top 100 COVID-19-related articles by AAS in the Altmetric database. Altmetrics could complement traditional citation count when assessing the dissemination of an article regarding COVID-19. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/21408.

Disparities in arthroplasty utilization for rotator cuff tear arthropathy.

BACKGROUND: Rotator cuff tear arthropathy (CTA) carries a significant symptomatic burden for patients. Reverse shoulder arthroplasty (RSA) is an effective treatment intervention for CTA. Disparities in musculoskeletal medicine are well documented; however, there is a paucity of literature on how social determinants of health affect utilization rates. The purpose of this study is to determine how social determinants of health affect the utilization rates of RSA. METHODS: A single-center retrospective review was conducted for adult patients diagnosed with CTA between 2015 and 2020. Patients were divided by those who underwent RSA and those who were offered RSA but did not undergo surgery. Each patient's zip code was used to determine the most specific median household income in the US Census Bureau database and compared to the multistate metropolitan statistical area median income. Income levels were defined by the US Department of Housing and Urban Development's (HUD's) 2022 Income Limits Documentation System and the Federal Reserve's (FED's) Community Reinvestment Act. Because of numeric restrictions, patients were grouped into racial cohorts of Black, White, and all other races. RESULTS: Patients of other races had significantly lower odds of continuing to surgery compared with White patients in models controlled for median household income (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.18-0.81, P = .01), HUD's 3 income levels (OR 0.36, 95% CI 0.18-0.74, P = .01), and FED's income levels (OR 0.37, 95% CI 0.17-0.79, P = .01). There was no significantly different odds of going on to surgery between FED income levels and median household income levels, but when compared with those with low HUD income, those below median had significantly lower odds of going on to surgery (OR 0.43, 95% CI 0.23-0.80, P = .01). CONCLUSION: Although contradictory to reported health care utilization for Black patients, our study supports reported disparities in utilization for other ethnic minorities. These findings may suggest that improvements in utilization efforts targeted Black-identifying patients but not necessarily other ethnic minorities. The findings of this study can help providers understand how social determinants of health play a role in the utilization of care for CTA and direct mitigation efforts to reduce disparities in access to adequate orthopedic care.

Impact of Large Database Studies on Orthopedic Surgery Literature: Are We Advancing the Field?

Background: While database studies have become more prevalent in the literature, there is concern over their value. In addition, the questions they are suitable to answer are limited. Questions/Purposes: We sought to determine the incidence of database studies in the orthopedic literature and in each subspecialty. In addition, we wanted to assess the impact of database studies on the literature by determining whether citations and Altmetric Attention Scores (AAS) varied by study type (studies using internal or external databases and those not using databases). Methods: We searched PubMed for articles published in impactful orthopedic surgery journals in the year 2018. All articles were discoverable on the Altmetric explorer portal database. Impact was determined by journal impact factor. Study design, subspecialty, number of citations, and AAS were obtained. Univariable analyses were conducted between study type, demographic variables, and the outcome of either citation count or AAS. Multivariable analyses were performed to identify independent predictors of the primary outcomes. Subgroup analyses were performed to differentiate the impact of external and internal database studies compared with non-database studies. Results: A total of 2684 total articles were eligible for inclusion. Of these, 366 studies (13.6%) were database studies. Hip and knee articles had the greatest incidence of database studies. Database studies had significantly more citations (5.9 vs 4.0) and significantly higher AAS (12.8 vs 11.3) compared with non-database studies. External database studies had significantly more citations (6.7 vs 4.8) and significantly higher AAS (14.0 vs 10.7) than internal database studies. Internal database studies had higher traditional citation counts but similar AAS to non-database studies. Conclusions: In 2018, database studies in well-reputed orthopedic journals had a greater number of citations but similar AAS compared with non-database studies. Further studies are warranted.

The exeter cemented stem provides outstanding long-term fixation and bone load at 15 years follow-up: A systematic review and meta-analysis.

PURPOSE: Since its introduction in 1988, the double-tapered polished Exeter cemented stem has been widely adopted in primary total hip arthroplasty (THA). Despite the results coming from the arthroplasty registries have proven great survivorship, the aim of this study was to dig deeper and describe the modes of failure of the Exeter stem at 15 years follow-up while reporting the clinical and radiographic outcomes. METHODS: A search of PubMed, MEDLINE, and Embase was performed using the Preferred Reporting Items for Systematic Review and Meta-Analyses since inception of database to January 2022. A meta-analysis was performed on stem's failure rates and clinical outcomes using random effects models. Publication bias was assessed with funnel plots. RESULTS: Overall, ten studies met the inclusion criteria with 2167 hips at mean 14.8 ± 4.1 years follow-up. The meta-effect estimate for revision rate for stem-related reasons was 3.8% (CI 95% 2.1-5.6, p < 0.01). The meta-effect for revision rate for stem aseptic loosening (AL) was 0.22% (CI 95% 0-0.4, p = 0.048) and for periprosthetic fracture was 0.6% (CI95% 0.3-0.9, p < 0.001). The meta effect estimate for Oxford Hip Score (OHS) at final follow-up was 32.4 (moderate; CI 95% 23.2-41.6, p <0.001) with and heterogeneity among the studies of I2 0%. Radiolucent lines were reported in 5.5% of cases, with 1.0% of cases (21 hips) reported to be progressive. CONCLUSION: Current evidence suggests that the Exeter cemented stem not only has proven long-term outstanding reliability with a revision rate of 3.8%, but also incredibly low revision rates for AL (0.22%) and periprosthetic fracture (0.6%). It is suitable for a variety of indications, and the consistent radiological appearances indicate durable fixation and load transmission while being associated with a remarkably low stem-related complication rate.

An Analysis of Epidemiological Factors in Heart Failure Outcomes.

Background Various socioeconomic and demographic factors play a role in determining treatment outcomes across numerous conditions. Different studies have shown that certain demographic factors, such as income status, directly correlate with treatment outcomes. In this study, we analyze the effect of some of these variables, namely, insurance and age, on various endpoints, including length of stay and discharge status, among heart failure patients. Methodology The data used in this project were retrieved from the HealthCare Utilization Project. We sorted the data by insurance, age, length of stay, and discharge status. To compare discharge status between different insurance types and age groups, we used Stata to compute odds ratios and 95% confidence intervals. To compare the length of stay among different age groups and insurance types, we conducted an unpaired two-tailed Student's t-test. Results Across all age groups, we found that younger patients with heart failure are more likely to discharge against medical advice compared to older patients. The average length of stay for heart failure patients was the same across all age groups except those 85 and older. Moreover, patients with a lower socioeconomic status, as determined by insurance type, were more likely to discharge against medical advice and less likely to die within hospitals. Conclusions Our results speak to the socioeconomic inequalities seen in medicine today. Studies have shown that those with a lower socioeconomic status tend to have worse outcomes across various conditions. Our analysis shows this phenomenon holds true for heart failure as well. In addition, our study helps to determine which groups are at higher risk of making medical decisions, such as discharging against medical advice, that will negatively affect their condition. Identifying these high-risk groups is a key first step to counteracting such behavior.

Perioperative Glucocorticoids in Patients With Rheumatoid Arthritis Having Total Joint Replacements: Help or Harm?

OBJECTIVE: The optimal strategy for perioperative glucocorticoid (GC) management in patients with rheumatoid arthritis (RA) on chronic GCs is unknown. Although there is a concern for hypotension if inadequate doses are used, higher GC exposure may increase perioperative complications. We aimed to investigate the relationships between perioperative GCs with hemodynamic instability and short-term postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in patients with RA. METHODS: This retrospective study included patients with RA who underwent THA and TKA. GC exposure was assessed by the total cumulative dose (in prednisone equivalents) during hospitalization. Perioperative complications and hypotension were assessed. RESULTS: Of 432 patients, 387 (90%) received supraphysiologic perioperative GC. Thirty percent of patients were using chronic GCs (mean daily dose, 7 ± 4 mg). Half (54%) underwent TKA. The median age was 65 years, and 79% were women. The median cumulative GC dose during hospitalization was 37 mg (interquartile range, 27-53.3). A lower cumulative dose of GC did not increase odds of hypotension during hospitalization (unadjusted odds ratio, 1.00 [95% confidence interval, 0.99-1.01]; P = 0.66)]. However, postoperative complications were higher among patients who received higher cumulative doses after adjustment for age, body mass index, home GC use, smoking, and Charlson Comorbidity Index. Risk of short-term complications increased by 8.4% (P = 0.017) for every 10-mg increase in GC dose. CONCLUSION: A lower GC dose was not associated with increased hypotension. However, patients with higher GC exposure were more likely to have hyperglycemia and other complications. These findings suggest that harms may be associated with high perioperative GC doses. Further research is needed to determine the optimal perioperative regimen for patients with RA.

Assessing the Dissemination of COVID-19 Articles Across Social Media With Altmetric and PlumX Metrics: Correlational Study.

BACKGROUND: The use of social media assists in the distribution of COVID-19 information to the general public and health professionals. Alternative-level metrics (ie, altmetrics) and PlumX metrics are new bibliometrics that can assess how many times a scientific article has been shared and how much a scientific article has spread within social media platforms. OBJECTIVE: Our objective was to characterize and compare the traditional bibliometrics (ie, citation count and impact factors) and new bibliometrics (ie, Altmetric Attention Score [AAS] and PlumX score) of the top 100 COVID-19 articles with the highest AASs. METHODS: The top 100 articles with highest AASs were identified with Altmetric Explorer in May 2020. The AASs, journal names, and the number of mentions in various social media databases of each article were collected. Citation counts and PlumX Field-Weighted Citation Impact scores were collected from the Scopus database. Additionally, AASs, PlumX scores, and citation counts were log-transformed and adjusted by +1 for linear regression, and Spearman correlation coefficients were used to determine correlations. RESULTS: The median AAS, PlumX score, and citation count were 4922.50, 37.92, and 24.00, respectively. The New England Journal of Medicine published the most articles (18/100, 18%). The highest number of mentions (985,429/1,022,975, 96.3%) were found on Twitter, making it the most frequently used social media platform. A positive correlation was observed between AAS and citation count (r2=0.0973; P=.002), and between PlumX score and citation count (r2=0.8911; P<.001). CONCLUSIONS: Our study demonstrated that citation count weakly correlated with AASs and strongly correlated with PlumX scores, with regard to COVID-19 articles at this point in time. Altmetric and PlumX metrics should be used to complement traditional citation counts when assessing the dissemination and impact of a COVID-19 article.

Pop a pill or give myself a shot? Patient perspectives of disease-modifying anti-rheumatic drug choice for rheumatoid arthritis.

OBJECTIVE: To assess how patients with rheumatoid arthritis (RA) decide whether to add oral disease-modifying anti-rheumatic drugs (DMARDs) versus injectable biologic DMARDs when methotrexate response is inadequate. METHODS: Using nominal group technique (NGT), RA patients answered the question "What sort of things are important to you when you make a decision between adding pills versus injectable medications to treat rheumatoid arthritis when methotrexate fails to control RA disease activity?" Patients nominated, discussed, and voted for the responses. RESULTS: Forty-seven RA patients participated: Birmingham (n=6 NG; 21 patients) and New York City (n=4 NG; 26 patients). They were predominantly female (85%), 70% white, with a mean age of 64.5 years and 58% had>10-year RA duration. Present/past DMARDs included methotrexate only in 6%, other traditional DMARDs in 15%, glucocorticoids in combination with traditional DMARDs in 11%, and biologics and/or Jak-kinase inhibitors in 68% of participants. Voted domains in order were: (1) efficacy/effectiveness and the onset/mode of action (78/282 votes); (2) side effects/fear of side effects (84/282 votes); (3) cost including out of pocket, co-payments and patient responsibility (54/282 votes); (4) convenience/frequency of use (27/282 votes); (5) doctor's opinion (20/282 votes); (6) other drugs/comorbidity/other patient's experience/effects on other people (3/282 votes); (7) fear of needles (8/282 votes); and (8) newness of the medication (8/282 votes). CONCLUSIONS: We identified the patient perspective regarding the choice between adding oral versus injectable DMARD once methotrexate failed to control RA disease activity. This knowledge can help in shared decision-making for DMARD choice in RA treatment.

Preoperative Anemia Independently Predicts Significantly Increased Odds of Short-Term Complications Following Aseptic Revision Hip and Knee Arthroplasty.

BACKGROUND: Preoperative anemia is an important risk factor for developing complications following revision hip (rTHA) and knee (rTKA) arthroplasty. We aim to determine the effect of anemia severity on 30-day postoperative complications following revision hip and knee arthroplasty. METHODS: A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program Database. All patients who underwent revision joint arthroplasty (rTJA) between 2006 to 2017 were identified and grouped based upon the hematocrit (Hct) level. Anemia was defined as Hct <36% for women and <39% for men, and further stratified into mild anemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe anemia (Hct <33% for both men and women). Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after TJA. RESULTS: A total of 8932 patients undergoing rTHA and 13,313 patients undergoing rTKA were included for analysis. On multivariate adjustment, patients undergoing rTHA with moderate to severe anemia had an increased odds of 5.437 (95% Confidence Interval (CI) 4.604 to 6.421; P < .001) of developing any postoperative complication. On multivariate adjustment, patients undergoing rTKA with moderate to severe anemia had increased odds of 6.731 (95% Confidence Interval (CI) 5.540 to 8.179; P < .001) of developing any postoperative complication. CONCLUSION: The increasing severity of anemia was associated with an increasing risk of developing any postoperative complication and death following revision hip and knee arthroplasty. There is a significant trend between diminishing preoperative hematocrit levels and increasing odds of postoperative complication.

Preoperative estimated glomerular filtration rate is a marker for postoperative complications following aseptic revision total hip arthroplasty.

INTRODUCTION: Revision total hip arthroplasty (rTHA) is increasingly performed but may carry a high rate of complication. This aim of the study was to determine if a decreased eGFR increases risks of postoperative complications following rTHA. METHODS: A retrospective cohort study using the American College of Surgeons National Quality Improvement Program Database was conducted. Patients undergoing rTHA between 2007 and 2014 were identified and stratified by glomerular filtration rates (eGFR): eGFR > 125 mL/min, eGFR 90-125 mL/min, eGFR 60-90 mL/min, eGFR 30-60 mL/min, and eGFR < 30 mL/min. The incidence of postoperative adverse events within 30 days, including cardiac, pulmonary, renal, septic, thromboembolic, urinary tract, and wound complications, blood transfusion, death, length of stay > 7 days, and unplanned return to the operating room, was assessed. The complication rates following rTHA were assessed with univariate and multivariate analysis with a significance set at p < 0.05. RESULTS: In total, 8898 revision THA procedures were included for analysis. 28.4% of patients that underwent rTHA developed a complication following surgery. Following adjustment, an eGFR of less than 30 mL/min independently increased the odds of any complication (OR 1.447; 95% C.I. 1.010-2.074; p = 0.044), cardiac complications (OR 3.344; 95% C.I. 1.040-10.752; p = 0.043), blood transfusion (O.R. 1.623; 95% C.I. 1.122-2.352; p = 0.010), and extended length of stay (O.R. 2.392; 95% C.I. 1.526-3.759; p < 0.001) when compared to normal renal function. CONCLUSIONS: Diminished eGFR of less than 30 mL/min increased the odds of total complications, cardiac complications, blood transfusions, and extended length of stay compared to normal renal function.

Hydroxychloroquine and Chloroquine in COVID-19: A Survey of Prescription Patterns Among Rheumatologists.

OBJECTIVE: With hydroxychloroquine (HCQ) and chloroquine (CQ) emerging as potential therapies for coronavirus disease 2019 (COVID-19), shortages have been reported. We aimed to understand how rheumatologists, one of the most common prescribers of HCQ/CQ, prescribed these medications to manage COVID-19 and to understand if their patients are affected by shortages. METHODS: Between April 8 and April 27, 2020, an online survey was distributed to a convenience sample of rheumatologists who practice medicine in a diverse range of settings globally, resulting in 506 responses. Adjusted Poisson regression models were calculated. RESULTS: Only 6% of respondents prescribed HCQ/CQ for COVID-19 prophylaxis, and only 12% for outpatient treatment of COVID-19. Compared to the United States, the likelihood of prescribing HCQ/CQ for prophylaxis was higher in India (adjusted risk ratio [aRR], 6.7; 95% confidence interval [CI], 2.7-16.8; p < 0.001). Further, compared to the United States and those with 1 to 5 years of experience, rheumatologists in Europe (aRR, 2.9; 95% CI, 1.6-5.3; p < 0.001) and those with 10+ years of experience (11-20 years: aRR, 2.5; 95% CI, 1.2-5.3; p = 0.015; 21+ years: aRR = 3.3; 95% CI, 1.4-7.4; p = 0.004) had a higher likelihood of prescribing HCQ/CQ for outpatient treatment. Of note, 71% of all rheumatologists reported that their patients were directly affected by HCQ/CQ shortages. CONCLUSION: The results suggest that only a small percentage of rheumatologists are prescribing HCQ/CQ for prophylaxis or outpatient treatment of COVID-19. Medication shortages experienced by large numbers of autoimmune disease patients are concerning and should play a role in decisions, especially given poor efficacy data for HCQ/CQ in COVID-19.

Important determinants of the patient choice between TNF- vs. non-TNF Biologic disease-modifying anti-rheumatic drugs (DMARDs) for active rheumatoid arthritis (RA).

OBJECTIVE: To assess why patients choose TNF- versus non-TNF biologics for treating active rheumatoid arthritis (RA) after methotrexate-failure. METHODS: Participants responded to the question "What sort of things help a patient decide the treatment choice between the two types of injectable biologics, TNF biologic versus non-TNF biologic, for treating active rheumatoid arthritis when methotrexate fails to control RA disease activity?" They nominated responses, discussed and then voted. RESULTS: Forty-four patients participated in 10 nominal groups (Birmingham; n=6; New York City: n=4), who were predominantly female (86%), 68% white, with a mean age of 65 (standard deviation [SD], 12) years. Present/past DMARDs included methotrexate in 91%, glucocorticoids in 11%, and biologics and/or Jak-inhibitors in 68% of participants. Pain and fatigue were mild-moderate with means of 3.9 (SD, 2.5) and 4.3 (SD, 2.5), respectively, on 0-10 scale; mean morning joint stiffness was 1.3hours (SD, 2.1). The number of groups that nominated each response and total votes were as follows: (1) Side effects/fear of side effects: 10/10; 31% votes (82/264); (2) Efficacy/ability to reduce joint damage: 9/10; 30% votes (80/264); (3) Doctor's opinion, 6/10; 12% votes (32/264); (4) Cost, 7/10; 9% votes (25/264); (5) Other drugs/comorbidity, 4/10; 12% votes (31/264); (6) Experience of others/information-seeking/own research, 2/10; 2% votes (5/264); (7) Newness, 1/10; 2% votes (6/264); and (8) Convenience/frequency of use, 1/10; 1% votes (3/264). CONCLUSIONS: We identified the patient perspective of choice between TNF versus non-TNF biologic for treating active RA. This knowledge can help in informative shared decision-making in clinical care.