Does Surgical Day of Week Affect Patient Outcomes and Hospital Costs Following Lumbar Fusion?

Background As the population ages, surgical intervention for degenerative spine conditions is increasing, and this causes a commiserate increase in healthcare expenditures associated with these procedures. Little research has been done on the effect of early-week versus later-week surgeries on patient outcomes, cost, and length of stay (LOS) in patients undergoing lumbar fusion surgery. The purpose of this study is to compare LOS, patient outcomes, and hospital costs between patients having surgery early in the week and later in the week. Methods A retrospective review of 771 patients undergoing a one-, two-, or three-level lumbar fusion from December 2020 to December 2023 at a single institution was performed. Demographics, surgical details, postoperative outcomes and cost were compared between patients who had surgery on Monday, Tuesday, and Wednesday, to those having surgery Thursday or Friday. Univariate and multivariate analyses were performed to compare the groups. Results There were no differences in age, sex, BMI, race, American Society of Anesthesiology (ASA) scores, Charlson Comorbidity Index (CCI) scores, number of operative levels or inpatient/outpatient status between early- and late-week surgeries. Postoperatively the only significant difference was cost, late-week surgeries were, on average, $3,697 more expensive than early-week surgeries ($26,506 vs. $22,809; p<0.001). On multivariate analysis late-week surgeries were 2.47 times more likely to have a non-home discharge (OR: 2.47, 95% CI: 1.24 to 4.95; p=0.010) and 2.19 times more likely to have a 30-day readmission (OR: 2.19, 95% CI:1.01 to 4.74; p=0.044) Additionally, late-week surgeries were $2,041.55 (ß:2,041.55, 95% CI: 804.72 to 3,278.38; p=0.001) more expensive than early-week surgeries. Conclusions At our institution, patients undergoing one- to three-level lumbar fusion surgery on Thursday or Friday had a higher risk of non-home discharge, 30-day readmission, and incurred higher cost than those having early-week surgery. Further research is needed to elucidate the reasons for these findings and to evaluate interventions aimed at improving outcomes for patients undergoing surgery later in the week.

Trends in Patient-Reported Physical Function After Hip Fracture Surgery.

Background Hip fractures carry significant morbidity and mortality, yet studies assessing post-surgical functional recovery from the patient's perspective are scarce, lacking benchmarks against age-matched populations. This study aimed to identify factors influencing postoperative functional outcomes, compared to the lower 25th percentile of normal age-matched populations, and to compare postoperative physical function with one-year mortality following hip fracture surgery. Methodology A retrospective review of 214 hip fracture patients reporting to the emergency department (ED) from July 2020 to June 2023 was conducted, with all completing a three-month postoperative Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) survey. Primary outcomes included three-month PROMIS-PF scores, with secondary outcomes focusing on one-year mortality. Factors such as demographics, comorbidities, procedures, time to surgery, length of stay, and postoperative outcomes were analyzed for correlation. Multivariate logistic regression assessed predictors of achieving a PROMIS-PF T-score of at least 32.5, representing the bottom 25th percentile for age-matched populations, and the relationship between three-month PROMIS PF T-scores and one-year mortality. Results Surgery was performed within 24 hours of ED arrival in 118 (55.1%) patients, the average length of stay was 5.2 days, and 64 (29.9%) were discharged home. Total hip arthroplasty and home discharge correlated with higher physical function scores. In contrast, older age, higher American Society of Anesthesiologists scores, certain comorbidities, specific surgical procedures, and longer hospital stays were associated with lower scores. Fewer than half (102 [47.7%]) achieved functional levels comparable to the 25th percentile of age-matched populations. Multivariate analysis indicated chronic obstructive pulmonary disease and home discharge as predictors of achieving this threshold, while higher PROMIS-PF T-scores were associated with reduced one-year mortality. Conclusions Patients undergoing hip fracture surgery are unlikely to achieve high levels of physical function within the three-month postoperative period. Fewer than half of these patients will reach functional levels, and decreased early function is associated with an increased risk of one-year mortality.

Sex, drugs, and zebrafish: Acute exposure to anxiety-modulating compounds in a modified novel tank dive test.

This study investigated the effects of anxiogenic and anxiolytic drugs on zebrafish (Danio rerio) behaviour using a modified novel tank dive test with higher walls and a narrower depth. Zebrafish were administered chondroitin sulfate, beta-carboline, delta-9-tetrahydrocannabinol (THC), ethanol, and beta-caryophyllene, and their behaviours were evaluated for geotaxis, swimming velocity, and immobility. Both anxiogenic and anxiolytic compounds generally increased bottom-dwelling behaviour, suggesting that the tank's modified dimensions significantly influence zebrafish responses. EC50 values for ethanol showed a lower threshold for velocity reduction compared to zone preference. Chondroitin sulfate uniquely caused a sex-specific increase in male swimming velocity, whereas no other sex-differences were observed with any compound. Interestingly, the presence of drug-treated fish did not alter the behaviour of observer fish, suggesting limited social buffering effects. The findings underscore the complexity of zebrafish behavioural phenotypes and highlight the need for considering tank dimensions and multiple behavioural parameters to accurately assess the effects of anxiety-modulating drugs. This study demonstrates the utility of the modified novel tank dive test in providing nuanced insights into the behavioural effects of different pharmacological agents in zebrafish.

Associations of educational and marketing messages with beliefs about nicotine and reduced nicotine cigarettes.

INTRODUCTION: Widespread misperceptions about nicotine may have unintended effects on public health. We examined associations between existing messages about nicotine or tobacco and beliefs about nicotine and reduced nicotine cigarettes (RNC). METHODS: 2962 U.S. 18-45-year-olds were randomized in a May 2022 web-based survey to view one of 26 text-based messages about tobacco or nicotine from three sources: ongoing research (n = 8), messages authorized by FDA for VLN cigarettes (n = 6), and FDA's "From Plant to Product to Puff" campaign (n = 12); six messages from FDA's campaign did not reference nicotine and were treated as the reference source. Analyses examined associations between messages, grouped by source and individually, with beliefs about nicotine and RNC addictiveness and harms. RESULTS: Relative to FDA messages that did not reference nicotine, all message sources were associated with greater odds of a correct belief about nicotine (Odds Ratios [ORs] = 1.40-1.87, p's < 0.01); VLN messages were associated with greater correct beliefs about RNC addictiveness (b = 0.23, p < .05). No campaign produced greater correct beliefs about RNC harms. At the individual level, only five messages were associated with a correct belief about nicotine (ORs = 2.12-2.56, p-values < .01), and one with correct beliefs about RNC harms (b = 1.09, p < .05), vs. the reference message. CONCLUSIONS: Few existing messages improved understanding of the risks of nicotine separately from the risks of combustible products. Communication research is needed to promote greater public understanding of nicotine while minimizing unintended effects on nicotine and tobacco use.

Inpatient or Outpatient: Does Initial Disposition Affect Outcomes in Trimalleolar Ankle Fractures?

Background The repair of trimalleolar fractures can be challenging for surgeons and may be managed as an inpatient or an outpatient. However, it is often unclear whether these patients should be admitted immediately or sent home from the emergency department (ED). This study aims to evaluate trimalleolar fractures treated surgically in the inpatient or outpatient settings to evaluate differences in outcomes for these patients. Methods A retrospective chart review of 223 patients undergoing open reduction internal fixation of a trimalleolar ankle fracture was performed from January 2015 to August 2022. Patients were classified by whether the fixation was performed as an inpatient or outpatient. Outcomes of interest included time from injury to surgery, complications, ED returns, and readmissions within 90 days. Results Inpatients had significantly higher ASA scores, BMI, and rates of comorbidities. Inpatient treatment was associated with faster time to surgery (median 2.0 vs. 9.0 days) and fewer delayed surgeries more than seven days from injury (18.4 vs. 67.9%). There were no differences in complications, 90-day ED returns, readmissions, or reoperation between groups. Conclusions Inpatient admission of patients presenting with trimalleolar ankle fractures resulted in faster time to surgery and fewer surgical delays than outpatient surgery. Despite having more preoperative risk factors, inpatients experienced similar postoperative outcomes as patients discharged home to return for outpatient surgery. Less restrictive admission criteria may improve the patient experience by providing more patients with support and pain control in the hospital setting while decreasing the time to surgery.

Addressing Barriers to Timely Orthopaedic Follow-up for Foot and Ankle Fractures After Emergency Department Visits.

INTRODUCTION: Foot and ankle fractures present common challenges in emergency departments, warranting careful follow-up protocols for optimal patient outcomes. This study investigates the predictors of orthopaedic follow-up for these injuries after an emergency department (ED) visit. METHODS: A retrospective observational study of 1450 patients seen in the ED with foot or ankle fractures from July 2015 to February 2023 was conducted. All included patients were discharged with instructions to follow-up with an orthopaedic provider. Demographic data, fracture details, and follow-up patterns were extracted from medical records. Social vulnerability was assessed using the Centers for Disease Control (CDC) Social Vulnerability Index. Univariate and multivariate analyses were performed to identify predictors of follow-up. A subgroup analysis comparing patients who followed up >7 days from ED presentation (ie, delayed follow-up) to those who followed up within 7 days of presentation was then performed. Statistical significance was assessed at P < .05. RESULTS: Overall, 974/1450 (67.2%) patients followed up with orthopaedics at an average time of 4.16 days. After risk adjustment, Medicaid coverage (odds ratio [OR] = 0.56, P = .018), increased overall social vulnerability (OR = 0.83, P = .032), and increased vulnerability across the dimensions of socioeconomic status (P = .002), household characteristics (P = .034), racial and ethnic minority status (P = .007), and household type and transportation (P = .032) were all associated with lower odds of follow-up. Phalangeal fractures were also associated with decreased odds of follow-up (OR = 0.039, P < .001), whereas ankle fractures were more likely to follow-up (OR = 1.52, P = .002). In the subgroup analysis, patients of older age (P = .008), non-white race (P = .024), motor vehicle accident (MVA) (P = .027) or non-private insurance (P = .027), those experiencing phalangeal fractures (P = .015), and those seen by an orthopaedic provider in the ED (P = .006) were more likely to present with delayed follow-up. CONCLUSION: Patients with increased social vulnerability and Medicaid insurance are less likely to seek follow-up care after presentation to the ED with foot and ankle fractures.

Rapid Osteoarthritis and Femoral Head Collapse: A Case Series.

Introduction: Rapidly progressive hip osteoarthritis (OA) leading to femoral head collapse (FHC) following intra-articular (IA) corticosteroid injections is a perplexing variant of OA. We explored eight cases of chronic joint pain treated with IA corticosteroid injections. Subsequently, they experienced swift deterioration of the femoral head integrity within as little as 10 weeks. These cases underscore the need for a comprehensive assessment of risk factors versus benefits in this patient population. Case Report: The study reveals a complex interplay between comorbidities, treatments, and outcomes. Patients exhibited various health factors, including obesity, smoking history, cancer treatment, and deficiencies in Vitamin D levels, which have been found to increase the risk of FHC. Furthermore, the study explores the chondrotoxicity of corticosteroids and local anesthetics used in IA injections. In vitro studies show complete loss of chondrocyte viability after a single dose of corticosteroids, potentially leading to cartilage degradation. In addition, local anesthetics may induce cellular demise and structural alterations in the articular cartilage. These factors highlight various influences affecting treatment outcomes in patients with OA. Conclusion: In conclusion, this case series highlights the rare adverse outcome of rapidly progressive hip OA and FHC following IA corticosteroid injections and possible risk factors. While a definitive etiology remains unclear, the study provides valuable conclusions to aid in future treatment decision-making.

Children's and adolescents' perspectives on living with advanced cancer: A meta-synthesis of qualitative research.

PURPOSE: The quality of life (QOL) experiences of children and adolescents living with advanced cancer have been under-explored. Enhancing QOL for this population is a dominant goal of their healthcare yet, there has been little research identifying aspects that impact their QOL. The purpose of this meta-synthesis was to identify themes of QOL informed from the voices of children and adolescents living with advanced cancer. METHODS: This meta-synthesis utilized meta-ethnography to synthesize data from individual studies in order to develop new conceptual understanding of what is important to children and adolescents about their lives when living with advanced cancer. RESULTS: Our analysis identified themes of QOL relevant to children and adolescents with advanced cancer: (1) feeling supported and wanting to support others; (2) re-establishing normal; (3) suffering and emotional distress; (4) new perspectives; (5) maintaining autonomy; and (6) awareness of time. These themes differed from more traditional dimensions of QOL often applied to children and adolescents with cancer. CONCLUSION: This research is novel as its developed themes originated from the direct voices and expressed perspectives of children and adolescents living with advanced cancer. This is a significant initial step toward both understanding QOL in this specific context and the measurement of QOL for this population.

How children and adolescents understand the quality of their lives while living with advanced cancer that is difficult to cure is largely unknown and has not been extensively studied. A significant number of children and adolescents will live with advanced cancer however, it is not well-understood how children and adolescents define their quality of life (QOL) and which aspects of their lives feel meaningful to them while living with advanced cancer. This is important as their understanding and perspectives of their QOL might be very different from what their parents and healthcare professionals caring for them might identify as meaningful to their QOL. This research used the voices of children and adolescents with advanced cancer that were included in diverse research studies examining children and adolescents' experiences living with advanced cancer to develop themes of QOL for this group of young people. It was important to focus on their voices as we wanted to know directly from children and adolescents living with advanced cancer what feels meaningful and relevant to their lives. Our research identified aspects of QOL important to children and adolescents with advanced cancer that are different from how QOL is traditionally understood for children and adolescents with cancer. These findings can contribute to enhancing the healthcare of children and adolescents living with advanced cancer by suggesting that children and adolescents with advanced cancer have distinct QOL experiences and needs.

Same-Day Discharge Does Not Increase Resource Utilization Within One Year of Total Joint Arthroplasty.

BACKGROUND: While the safety of rapid recovery total joint arthroplasty is well established, less is known about its impact on postoperative care utilization patterns. We wished to examine whether same-day discharge-and its associated presumed reduction in hospital-based postoperative care and education-translates to the need for more postoperative support during the 1-year recovery period. METHODS: A retrospective review of 1,237 total hip arthroplasty (THA) and 1,710 total knee arthroplasty (TKA) patients who had 0- or 1-day length of stay (LOS) from January 2020 to October 2023 was conducted. The primary outcome was the number of follow-up visits with total joint arthroplasty providers at our institution during the 1-year postoperative period. Secondary outcomes included 30-day emergency department returns, readmissions, 1-year physical therapy utilization, and improvement in Patient-Reported Outcomes Measurement Information System Physical Function scores at 6 to 12 months postoperatively. Bivariate and multivariable analyses were performed to compare outcomes between 0-day and 1-day LOS THA and TKA patients. RESULTS: In both the THA and TKA populations, 0-day LOS patients were younger, had a lower average body mass index, were more likely to be White, men, and had an American Society of Anesthesiologists score < 3 than 1-day LOS patients. After controlling for differences between groups, no significant differences in the number of one-year follow-up visits, physical therapy visits, emergency department returns, or readmissions were seen between 0 and 1-day THA or TKA patients. In TKA patients, 1-day LOS was associated with lower improvements in Patient-Reported Outcomes Measurement Information System Physical Function scores. CONCLUSIONS: After risk adjustment, same-day discharge of THA and TKA patients did not result in increased resource utilization during the one-year postoperative period. In the setting of a coordinated joint arthroplasty program with nurse navigator support, same-day discharge can be safely performed without increasing the need for postoperative care in appropriately selected patients undergoing both THA and TKA.

The Relationship Between Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity Scores and Early Postoperative Pain and Opioid Consumption After Lumbar Fusion.

Background The Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and pain intensity measures quantify separate dimensions of pain from the patient's perspective. This study aimed to assess differences in these outcomes and to evaluate whether baseline PROMIS pain scores could be used as a leading indicator of increased pain and opioid consumption during early recovery after lumbar fusion. Methods A retrospective review of 199 consecutive patients undergoing posterolateral fusion (PLF) at a single institution was performed. All patients underwent one to three level lumbar PLF and preoperatively completed the PROMIS pain intensity and PROMIS pain interference measures. Multivariate linear regression was used to assess the relationship between preoperative PROMIS scores and postoperative pain numeric rating scale (NRS) and oral morphine milligram equivalents (OMME) by day after controlling for age, sex, and body mass index (BMI). Results In comparison to patients with the lowest preoperative pain intensity scores, those with the highest scores required significantly more OMME on postoperative day (POD) zero and one (both p<0.05) and had higher pain NRS on POD one (p=0.02). Patients with the highest pain interference scores reported higher pain NRS on POD zero (p=0.02) but required similar OMME at all time points. After controlling for age, sex, and BMI, each one-point increase in preoperative PROMIS pain interference scores was associated with increased OMME on POD zero (ß=0.29, p=0.04) and POD one (ß=0.64, p=0.03). Conclusions Patients with high pain intensity reported higher levels of pain and required more opioids during the first 24 hours postoperatively, while those with high pain interference reported higher levels of pain on the day of surgery but utilized similar amounts of opioids. After risk adjustment, increased baseline PROMIS pain interference scores - but not pain intensity - were associated with increased opioid use. These results suggest that both measures should be considered when identifying patients at risk for increased pain and opioid consumption after PLF.

Comparison of Postoperative Outcomes of Patients Undergoing Total Hip and Total Knee Arthroplasty Following a Diagnosis of Dementia: A TriNetX Database Study.

Background: As life expectancy improves for patients with dementia, the demand for mobility-improving surgeries such as total joint arthroplasty (TJA) will increase. There is little research on patients with dementia undergoing TJA, although dementia has been shown to be a risk factor for complications. The purpose of this study is to compare postoperative outcomes of patients with dementia undergoing TJA at 90 days, 2 years, and 5 years. Methods: The TriNetX database was retrospectively queried for all patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were divided into cohorts by preoperative diagnosis of dementia and propensity score matched. The following outcomes were evaluated between groups at 90 days, 2 years, and 5 years postoperatively: revision, resection arthroplasty, closed reduction (THA only), femur fracture plating, and prosthetic joint infection. Readmission and manipulation under anesthesia (TKA only) were evaluated at 90 days postoperatively. Univariate and multivariate analyses were performed. Results: After matching, there were no differences in demographics or comorbidities between groups. TKA (odds ratio [OR] = 1.75, 95% confidence interval [CI] 1.42-2.15, P < .001) and THA (OR = 2.17, 95% CI 1.92-2.45, P < .001) patients with dementia were more likely to be readmitted than patients without dementia. At 2 years (OR = 2.07, 95% CI 1.14-3.77, P = .015) and 5 years (OR = 2.14, 95% CI 1.32-3.48, P = .002) postoperatively, THA patients with dementia were more likely to have proximal femur fracture plating than patients without dementia. Conclusions: Patients undergoing THA with dementia had worse outcomes than patients undergoing THA without dementia and TKA with dementia. The overall rate of complications was low, and a diagnosis of dementia should not be an absolute contraindication to proceeding with TJA.

Managing an epidemic within a pandemic: orthopedic opioid prescribing trends during COVID-19.

INTRODUCTION: In response to the opioid epidemic, a multitude of policy and clinical-guideline based interventions were launched to combat physician overprescribing. However, the sudden rise of the Covid-19 pandemic disrupted all aspects of healthcare delivery. The purpose of this study was to evaluate how opioid prescribing patterns changed during the Covid-19 pandemic within a large multispecialty orthopedic practice. MATERIALS AND METHODS: A retrospective review of 1,048,559 patient encounters from January 1, 2015 to December 31, 2022 at a single orthopedic practice was performed. Primary outcomes were the percent of encounters with opioids prescribed and total morphine milligram equivalents (MMEs) per opioid prescription. Differences in outcomes were assessed by calendar year. Encounters were then divided into two groups: pre-Covid (1/1/2019-2/29/2020) and Covid (3/1/2020-12/31/2022). Univariate analyses were used to evaluate differences in diagnoses and outcomes between periods. Multivariate analysis was performed to assess changes in outcomes during Covid after controlling for differences in diagnoses. Statistical significance was assessed at p < 0.05. RESULTS: The percentage of encounters with opioids prescribed decreased from a high of 4.0% in 2015 to a low of 1.6% in 2021 and 2022 (p < 0.001). MMEs per prescription decreased from 283.6 ± 213.2 in 2015 to a low of 138.6 ± 100.4 in 2019 (p < 0.001). After adjusting for diagnoses, no significant differences in either opioid prescribing rates (post-COVID OR = 0.997, p = 0.893) or MMEs (post-COVID ß = 2.726, p = 0.206) were observed between the pre- and post-COVID periods. CONCLUSION: During the Covid-19 pandemic opioid prescribing levels remained below historical averages. While continued efforts are needed to minimize opioid overprescribing, it appears that the significant progress made toward this goal was not lost during the pandemic era.

The association between losartan potassium prescription and postoperative outcomes following total knee arthroplasty: A TriNetX analysis.

BACKGROUND: Total knee arthroplasty (TKA) is a common surgical procedure performed to alleviate pain and improve functional outcomes in patients with knee osteoarthritis and rheumatoid arthritis who have failed conservative treatments. Arthrofibrosis has been extensively studied due to its negative impact on TKA outcomes. Losartan, an angiotensin receptor blocker (ARB), has the potential to improve TKA outcomes by inhibiting TGF-ß and decreasing fibrosis. This study aims to analyze a large-scale, real-world healthcare database to investigate the association between losartan potassium prescription and postoperative outcomes such as readmissions, ED visits, and the need for MUA or revision TKA. HYPOTHESIS: Based on previous literature and the nature of ARBs, it is expected that the addition of losartan will aid in better outcomes for patients following a primary TKA. PATIENTS AND METHODS: In this retrospective observational study, the TriNetX Research Network (TriNetX) database was queried as of June 21, 2023. All patients who underwent a primary total knee arthroplasty (TKA) prior to June 21, 2022 were included. Patients were then divided into two cohorts by whether they had an active losartan potassium prescription within the year prior to their surgery to within 90days postoperatively. Patients were then propensity-matched to eliminate differences in demographics and comorbidities. RESULTS: Losartan TKA patients were 1.18 [OR: 0.85 (95% CI: 0.79-0.90), p<0.001] times less likely to be readmitted within 90days and were 1.15 (OR: 0.87 (95% CI: 0.79-0.96); p=0.009) times less likely to undergo a manipulation under anesthesia (MUA) within the 1-year postoperative period. There were no statistically significant differences in rates of emergency department (ED) visits at 90days postoperatively or revision TKAs at 1year postoperatively. DISCUSSION: In conclusion, patients with an active losartan prescription prior to TKA had a significantly lower likelihood of readmission within 90days and a lower likelihood of undergoing MUA within the 1-year postoperative period compared to patients not taking losartan. This presents an opportunity for further clinical investigation to explore the value of losartan in TKA. LEVEL OF EVIDENCE: III; an observational cohort study.

Disparities in Patient Reported Outcome Measure Completion Rates and Baseline Function in Newly Presenting Spine Patients.

STUDY DESIGN: Retrospective Review. OBJECTIVE: The purpose of this study was to evaluate disparities in patient reported outcome measures (PROM) completion rates and baseline function scores among newly presenting spine patients. SUMMARY OF BACKGROUND DATA: Prior studies have demonstrated that minority patients and those of low socioeconomic status may present with worse physical and mental health on PROMs. As PROMs are increasingly used in clinical care, research, and health policy, accurate assessment of health status among populations relies on the successful completion of PROM instruments. METHODS: A retrospective review of 10,803 consecutive new patients presenting to a single multidisciplinary spine clinic from June 2020 to September 2022 was performed. Univariate statistics were performed to compare demographics between patients who did and did not complete PROMs. Multivariable analysis was used to compare PROM instrument completion rates by race, ethnicity, and Social Vulnerability Index (SVI) and baseline scores among responders. RESULTS: 68.4% of patients completed PROMs at the first clinic visit. After adjusting for age, sex, body mass index, and diagnosis type, patients of non-white race (OR=0.661, 95%-CI=0.599-0.729, P<0.001), Hispanic ethnicity (OR=0.569, 95%-CI=0.448-0.721, P<0.001), and increased social vulnerability (OR=0.608, 95%-CI=0.511-0.723, P<0.001) were less likely to complete PROMs. In the multivariable models, patients of non-white race reported lower levels of physical function (ß=-6.5, 95%-CI=-12.4 to -0.6, P=0.032) and higher levels of pain intensity (ß=0.6, 95%-CI=0.2-1.0, P=0.005). Hispanic ethnicity (ß=1.5, 95%-CI=0.5-2.5, P=0.004) and increased social vulnerability (ß=1.1, 95%-CI=0.4-1.8, P=0.002) were each associated with increased pain intensity. CONCLUSION: Among newly presenting spine patients, those of non-white race, Hispanic ethnicity, and with increased social vulnerability were less likely to complete PROMs. As these subpopulations also reported worse physical function or pain intensity, additional strategies are needed to better capture patient reported health status in order to avoid bias in clinical care, outcomes research and health policy.

Outcomes in Lumbar Fusion Patients Stratified by the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) Classification System.

Background and objective The Meyerding classification system remains the most common classification system for spondylolisthesis based on the percentages of vertebral translation. However, the majority of patients with degenerative disease fall into Grade 1, limiting its utility in this subset of patients. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system provides a simple radiographic framework for classifying degenerative lumbar spondylolisthesis (DLS) patients by incorporating disc height, kyphosis, and anterior translation. The purpose of this study was to evaluate how clinical characteristics, treatments, and outcomes vary across different CARDS groups in patients undergoing one- or two-level lumbar fusion for DLS. Methods The patients were classified into one of the following four CARDS groups - Type A: advanced disc space collapse with no evidence of kyphosis; Type B: partially preserved disc space with less than 5.0 mm of translation; Type C: partially preserved disc space with greater than 5.0 mm of translation; and Type D: kyphotic alignment. Univariate analyses were performed to compare demographics, symptoms, clinical outcomes, and Patient-Reported Outcomes Measurement Information System (PROMIS) physical (PH) and mental health (MH) scores across groups. Results Ninety-one patients were included in the study. Based on the CARDS classification, there were three (3%) Type A patients, 25 (28%) Type B, 58 (64%) Type C, and five (5%) Type D. No significant differences in baseline demographics, symptom duration, or PROMIS scores were observed across groups. Interbody utilization varied, ranging from 19% in CARDS C (n=11) to 60% in CARDS B (n=15) and D (n=3) patients (p=0.005). Thirty-day clinical outcomes were similar across groups. At an average follow-up of 8.9 months, improvements in PROMIS PH and MH scores and rates of clinically significant improvement were similar across groups. Conclusions Based on our findings, patients undergoing lumbar fusion for DLS present with similar demographic and clinical characteristics and experience similar clinical and patient-reported outcomes when stratified using the CARDS classification system. Posterolateral fusion (PLF) can be effective for various radiographic presentations of DLS. Further research is warranted to assess the utility of CARDS in preoperative planning.

Social Determinants of Health in Maryland Hip Arthroscopy Patients.

Background Prior studies have demonstrated racial and socioeconomic disparities in patient-reported outcome measure (PROM) completion rates, and improvement exists across multiple orthopedic conditions. The purpose of this study was to assess whether these disparities are present in patients undergoing hip arthroscopy (HA) procedures. Methods A retrospective study of 306 patients undergoing HA from 2021 to 2023 was performed. Social determinants of health (SDOH) were compared between HA patients and the general Maryland population. Patients were then classified by whether they completed baseline and six-month PROMs (Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) instrument). Patients who completed PROMIS-PF were classified by whether or not they achieved minimal clinically important difference (MCID) at six months. Demographics and SDOH were compared using univariate analyses between patients who did and did not complete PROMs and between those who did and did not achieve MCID. SDOH were evaluated at the zip-code level using regional health information exchange measures. Results Compared to the Maryland population, HA patients resided in areas of lower social vulnerability. Preoperative and six-month PROMs were completed by 102 (33%) patients. No significant differences in demographics or any SDOH were found between patients who did and did not complete PROMs. Six-month MCID was achieved in 75 of 102 (74%) patients with complete PROMs; no significant differences in demographics or SDOH were observed between patients who did and did not achieve MCID. Conclusions For patients undergoing HA, disparities in patient-reported outcome completion rates and postoperative functional improvement do not appear to be present across demographics and SDOH, indicating equitable care is being delivered.

Mindful awareness and resilience skills for adolescents (MARS-A): a mixed-methods study of a mindfulness-based intervention for a heterogeneous adolescent clinical population.

OBJECTIVES: Mindful Awareness and Resilience Skills for Adolescents (MARS-A) is a mindfulness-based intervention adapted for the adolescent population. While previous studies have explored the benefits of MARS-A in various single-diagnosis populations, the aim of this study was to assess MARS-A for a heterogenous clinical adolescent population with mental health and/or chronic diagnoses, focusing on the underlying suffering present in all these conditions rather than its effects on a single diagnosis itself. METHODS: Qualitative data was collected through interviews to understand post-intervention participant perspectives and experiences. Quantitative data was collected through measures to investigate preliminary secondary outcomes. RESULTS: After participating in MARS-A, participants reported qualitative benefits in enhanced well-being, including coping with difficult emotions and managing sleep and/or pain. Quantitative results showed a reduction in functional disability, psychological distress, perceived stress, and depressive symptoms; increase in positive affect; and benefit in coping with pain and chronic conditions. CONCLUSIONS: MARS-A shows great potential in a heterogeneous clinical adolescent population.

Social vulnerability adversely affects emergency-department utilization but not patient-reported outcomes after total joint arthroplasty.

INTRODUCTION: Multiple studies demonstrate social deprivation is associated with inferior outcomes after total hip (THA) and total knee (TKA) arthroplasty; its effect on patient-reported outcomes is debated. The primary objective of this study evaluated the relationship between social vulnerability and the PROMIS-PF measure in patients undergoing THA and TKA. A secondary aim compared social vulnerability between patients who required increased resource utilization or experienced complications and those who didn't. MATERIALS AND METHODS: A retrospective review of 537 patients from March 2020 to February 2022 was performed. The Centers for Disease Control Social Vulnerability Index (SVI) were used to quantify socioeconomic disadvantage. The cohort was split into THA and TKA populations; univariate and multivariate analyses were performed to evaluate primary and secondary outcomes. Statistical significance was assessed at p < 0.05. RESULTS: 48.6% of patients achieved PROMIS-PF MCID at 1-year postoperatively. Higher levels of overall social vulnerability (0.40 vs. 0.28, p = 0.03) were observed in TKA patients returning to the ED within 90-days of discharge. Increased overall SVI (OR = 9.18, p = 0.027) and household characteristics SVI (OR = 9.57, p = 0.015) were independent risk factors for 90-day ED returns after TKA. In THA patients, increased vulnerability in the household type and transportation dimension was observed in patients requiring 90-day ED returns (0.51 vs. 0.37, p = 0.04). CONCLUSION: Despite an increased risk for 90-day ED returns, patients with increased social vulnerability still obtain good 1-year functional outcomes. Initiatives seeking to mitigate the effect of social deprivation on TJA outcomes should aim to provide safe alternatives to ED care during early recovery.

Addressing the Challenge of Spine Patient Triage: Development of a Simple Algorithm for Identification of Potential Surgical Candidates.

INTRODUCTION: Given that most spine conditions do not require surgical intervention, using surgeons to manage the subset of patients potentially requiring surgery is the most efficient resource allocation strategy. The purpose of this study was to develop a simple algorithm for identifying patients most likely to require spine surgery that could be used to appropriately triage this population to surgeons. METHODS: A retrospective review of 5,886 consecutive new patients presenting to a multidisciplinary spine clinic from March 2021 to September 2022 was conducted. The primary outcome was whether a patient underwent spine surgery during the study period. A total of 64 independent variables were recorded from patient intake and the first visit. A gradient boosted model was generated to identify the independent variables most associated with undergoing surgery. The five most important variables were entered into a multiple logistic regression model, and a simplified decision support tool was generated and assessed. RESULTS: Overall, 440 of 5886 patients (7.5%) underwent surgery during the study period. The following variables were identified as the top five predictors of spine surgery: patient goal of interest in learning about spine surgery, history of spine injections, difficulty walking a mile, radicular symptoms greater than axial symptoms, and increased age. Each of these variables was confirmed to be independently associated with undergoing surgery (all P < 0.001). The decision support tool yielded a sensitivity of 60.0%, specificity of 76.6%, likelihood ratio of 2.56, positive predictive value of 17.2%, and negative predictive value of 96.0% for predicting surgery. An AUC of 0.683 was achieved. CONCLUSION: A simple 5-question algorithm incorporating patient demographics, symptoms, treatment history, physical function, and patient goals may improve the ability of practices to identify potential spine surgery candidates before their first visit. Prospective application and evaluation of the algorithm to evaluate whether it improves the triage of appropriate patients to spine surgeons is warranted.

Non-White Race and Concomitant Orthopedic Conditions Are Risk Factors for Failure to Achieve Clinically Relevant Improvement After Total Knee Arthroplasty.

BACKGROUND: Data from the American Joint Replacement Registry demonstrate that 1-year minimal clinically important difference (MCID) achievement rates after total knee arthroplasty (TKA) are substantially lower when using general patient reported outcome measures, such as Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), than joint specific measures. The purpose of this study was to evaluate patient characteristics and outcomes associated with MCID achievement after TKA using the PROMIS-PF measure. METHODS: A retrospective review of 263 patients undergoing TKA with preoperative and 1-year postoperative PROMIS-PF scores from March 12, 2020 to February 8, 2022 was performed. Three multivariate models were built to evaluate predictors of MCID achievement. Preoperative predictors evaluated included demographics, comorbidities, history of spine and knee surgery, and baseline PROMIS-PF. Postoperative clinical outcomes evaluated included lengths of stay, discharge statuses, complications, and utilizations of other orthopaedic services. RESULTS: There were 109 patients (41%) who achieved an MCID at 1-year postoperatively. Non-white patients had 2.17 times lower odds of achieving MCID. No clinical outcomes assessed were independently predictive of MCID achievement. During the 1-year postoperative period, 63% of patients sought care for another orthopaedic condition. Patients requiring postoperative injections on another joint had a 2.27 times lower odds of achieving MCID. Those seen for spine conditions postoperatively had a 2.44 lower odds of achieving MCID. CONCLUSIONS: Race, postoperative injections, and treatment for spine conditions after TKA were independent predictors of failure to achieve MCID. These results may guide preoperative patient consultation and risk-adjustment in future studies using PROMIS-PF as an endpoint for evaluation of TKA outcomes.