Synthesis of 'joint class' curricula at high volume joint replacement centres and a preliminary model for development and evaluation.

RATIONALE: Preoperative patient education through 'joint class' has potential to improve quality of care for total joint replacement (TJR). However, no formal guidance exists regarding curriculum content, potentially resulting in inter-institutional variation. OBJECTIVE: We aimed to (a) synthesize curriculum components of 'joint classes' across high-volume institutions and (b) develop a preliminary theory of change model for development and evaluation guided by the existing curricula and related literature. METHODS: We reviewed 'joint class' curricula from the websites of the 10 highest-volume TJR centres (by average annual 2017-2019 volume) that publicly disclosed this information. Two reviewers qualitatively compared available content and noted common categories, which were synthesized into key domains across institutions. We then reviewed the PubMed database for literature on pre-TJR patient education and education needs in the past 10 years. Drawing on our curriculum synthesis and related literature, we proposed a theory of change model: hypothesized mechanisms through which 'joint class' confers benefits to patients and health systems. RESULTS: We identified 30 categories in our review of existing class content, which we synthesized into seven key domains: (I) Practical Elements, (II) Logistics, (III) Medical Information, (IV) Modifiable Risk Factors, (V) Expected Outcomes, (VI) Patient Role in Recovery and (VII) Enhanced Education. Variation across institutions was noted. Our preliminary model based on the curriculum synthesis and related literature on the impact of 'joint class' includes three levels: (1) Practical Elements ('joint class' accessibility and information quality), (2) Class Goals (increased health literacy, increased adherence, risk mitigation, realistic expectations, and reduced anxiety) and (3) Target Outcomes (improved clinical outcomes, positive patient experience and increased patient satisfaction). CONCLUSION: Our synthesis identified core common topics included in pre-TJR education but also highlighted variation across institutions, supporting opportunities for standardization. Clinicians and researchers can use our preliminary model to systematically develop and evaluate 'joint classes,' with the goal of establishing a standard of care for TJR preoperative education.

Impact of tobacco usage on readmission and complication rates following shoulder replacement surgery: A study of 164,527 patients.

Background: Tobacco carcinogens have adverse effects on bone health and are associated with inferior outcomes following orthopedic procedures. The purpose of this study was to assess the impact tobacco use has on readmission and complication rates following shoulder arthroplasty. Methods: The 2016-2018 National Readmissions Database was queried to identify patients who underwent anatomical, reverse, and hemi-shoulder arthroplasty. ICD-10 codes Z72.0 × (tobacco use disorder) and F17.2 × (nicotine dependence) were used to define "tobacco-users." Demographic, 30-/90-day readmission, surgical complication, and medical complication data were collected. Inferential statistics were used to analyze complications for both the cohort as a whole and for each procedure separately (i.e. anatomical, reverse, and hemiarthroplasty). Results: 164,527 patients were identified (92% nontobacco users). Tobacco users necessitated replacement seven years sooner than nonusers (p < 0.01) and were more likely to be male (52% vs. 43%; p < 0.01). Univariate analysis showed that tobacco users had higher rates of readmission, revisions, shoulder complications, and medical complications overall. In the multivariate analysis for the entire cohort, readmission, revision, and complication rates did not differ based on tobacco usage; however, smokers who underwent reverse shoulder arthroplasty in particular were found to have higher 90-day readmission, dislocation, and prosthetic complication rates compared to nonsmokers. Conclusion: Comparatively, tobacco users required surgical correction earlier in life and had higher rates of readmission, revision, and complications in the short term following their shoulder replacement. However, when controlling for tobacco usage as an independent predictor of adverse outcomes, these aforementioned findings were lost for the cohort as a whole. Overall, these findings indicate that shoulder replacement in general is a viable treatment option regardless of patient tobacco usage at short-term follow-up, but this conclusion may vary depending on the replacement type used.

Sleep Disturbance Trends in the Short-Term Postoperative Period for Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Patients undergoing total joint arthroplasty (TJA) often experience preoperative/postoperative sleep disturbances. Although sleep quality generally improves > 6 months after surgery, patterns of sleep in the short-term postoperative period are poorly understood. This study sought to (1) characterize sleep disturbance patterns over the 3-month postoperative period and (2) investigate clinical and sociodemographic factors associated with 3-month changes in sleep. METHODS: This retrospective analysis of prospectively collected data included 104 primary elective TJA patients. Patients were administered the PROMIS Sleep Disturbance questionnaire preoperatively and at 2 weeks, 6 weeks, and 3 months postoperatively. Median sleep scores were compared between time points using Wilcoxon signed-rank tests, stratified by preoperative sleep impairment. A multivariable logistic regression model identified factors associated with 3-month clinically improved sleep. RESULTS: The percentage of patients reporting sleep within normal limits increased over time: 54.8% preoperatively and 58.0%, 62.5%, and 71.8% at 2 weeks, 6 weeks, and 3 months post-TJA, respectively. Patients with normal preoperative sleep experienced a transient 4.7-point worsening of sleep at 2 weeks ( P = 0.003). For patients with moderate/severe preoperative sleep impairment, sleep significantly improved by 5.4 points at 2 weeks ( P = 0.002), with improvement sustained at 3 months. In multivariable analysis, patients undergoing total hip arthroplasty (versus knee; OR: 3.47, 95% CI: 1.06 to 11.32, P = 0.039) and those with worse preoperative sleep scores (OR: 1.13, 95% CI: 1.04 to 1.23, P = 0.003) were more likely to achieve clinically improved sleep from preoperatively to 3 months postoperatively. DISCUSSION: Patients experience differing patterns in postoperative sleep changes based on preoperative sleep disturbance. Hip arthroplasty patients are also more likely to experience clinically improved sleep by 3 months compared with knee arthroplasty patients. These results may be used to counsel patients on postoperative expectations and identify patients at greater risk of impaired postoperative sleep. STUDY DESIGN: Retrospective analysis of prospectively collected data.

Previous Emergency Department Admission Is Associated With Increased 90-Day Readmission Following Cervical Spine Surgery: Evidenced Using Propensity Score Matching.

STUDY DESIGN: This was a retrospective case-control study. OBJECTIVE: The objective of this study was to evaluate whether prior emergency department admission was associated with an increased risk for 90-day readmission following elective cervical spinal fusion. SUMMARY OF BACKGROUND DATA: The incidence of cervical spine fusion reoperations has increased, necessitating the improvement of patient outcomes following surgery. Currently, there are no studies assessing the impact of emergency department visits before surgery on the risk of 90-day readmission following elective cervical spine surgery. This study aimed to fill this gap and identify a novel risk factor for readmission following elective cervical fusion. METHODS: The 2016-2018 Nationwide Readmissions Database was queried for patients aged 18 years and older who underwent an elective cervical fusion. Prior emergency admissions were defined using the variable HCUP_ED in the Nationwide Readmissions Database database. Univariate analysis of patient demographic details, comorbidities, discharge disposition, and perioperative complication was evaluated using a χ 2 test followed by multivariate logistic regression. RESULTS: In all, 2766 patients fit the inclusion criteria, and 18.62% of patients were readmitted within 90 days. Intraoperative complications, gastrointestinal complications, valvular, uncomplicated hypertension, peripheral vascular disorders, chronic obstructive pulmonary disease, cancer, and experiencing less than 3 Charlson comorbidities were identified as independent predictors of 90-day readmission. Patients with greater than 3 Charlson comorbidities (OR=0.04, 95% CI 0.01-0.12, P <0.001) and neurological complications (OR=0.29, 95% CI 0.10-0.86, P =0.026) had decreased odds for 90-day readmission. Importantly, previous emergency department visits within the calendar year before surgery were a new independent predictor of 90-day readmission (OR=9.74, 95% CI 6.86-13.83, P <0.001). CONCLUSIONS: A positive association exists between emergency department admission history and 90-day readmission following elective cervical fusion. Screening cervical fusion patients for this history and optimizing outcomes in those patients may reduce 90-day readmission rates.

Readmission and Associated Factors in Surgical Versus Non-Surgical Management of Spinal Epidural Abscess: A Nationwide Readmissions Database Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Spinal epidural abscess (SEA) is a rare but potentially life-threatening infection treated with antimicrobials and, in most cases, immediate surgical decompression. Previous studies comparing medical and surgical management of SEA are low powered and limited to a single institution. As such, the present study compares readmission in surgical and non-surgical management using a large national dataset. METHODS: We identified all hospital admissions for SEA using the Nationwide Readmissions Database (NRD), which is the largest collection of hospital admissions data. Patients were grouped into surgically and non-surgically managed cohorts using ICD-10 coding and compared using information retrieved from the NRD such as demographics, comorbidities, length of stay and cost of admission. RESULTS: We identified 350 surgically managed and 350 non-surgically managed patients. The 90-day readmission rates for surgical and non-surgical management were 26.0% and 35.1%, respectively (P < .05). Expectedly, surgical management was associated with a significantly higher charge and length of stay at index hospital admission. Surgically managed patients had a significantly lower risk of readmission for osteomyelitis (P < .05). Finally, in patients with a low comorbidity burden, we observed a significantly lower 90-day readmission rate for surgically managed patients (surgical: 23.0%, non-surgical: 33.8%, P < .05). CONCLUSION: In patients with a low comorbidity burden, we observed a significantly lower readmission rate for surgically managed patients than non-surgically managed patients. The results of this study suggest a lower readmission rate as an advantage to surgical management of SEA and emphasize the importance of SEA as a not-to-miss diagnosis.

Sentiment Analysis of Online Patient-Written Reviews of Vascular Surgeons.

BACKGROUND: Online patient reviews influence a patient's choice of a vascular surgeon. The aim of this study is to examine underlying factors that contribute to positive and negative patient reviews by leveraging sentiment analysis and machine learning methods. METHODS: The Society of Vascular Surgeons publicly accessible member directory was queried and cross-referenced with a popular patient-maintained physician review website, healthgrades.com. Sentiment analysis and machine learning methods were used to analyze several parameters. Demographics (gender, age, and state of practice), star rating (of 5 stars), and written reviews were obtained for corresponding vascular surgeons. A sentiment analysis model was applied to patient-written reviews and validated against the star ratings. Student's t-test or one-way analysis of variance assessed demographic relationships with reviews. Word frequency assessments and multivariable logistic regression analyses were conducted to identify common and determinative components of written reviews. RESULTS: A total of 1,799 vascular surgeons had public profiles with reviews. Female gender of surgeon was associated with lower star ratings (male = 4.19, female = 3.95, P < 0.01) and average sentiment score (male = 0.50, female = 0.40, P < 0.01). Younger physician age was associated with higher star rating (P = 0.02) but not average sentiment score (P = 0.12). In the Best reviews, the most commonly used one-words were Care (N = 999), Caring (N = 767), and Kind (N = 479), while the most commonly used two-word pairs were Saved/Life (N = 189), Feel/Comfortable (N = 106), and Kind/Caring (N = 104). For the Worst reviews, the most commonly used one-words were Pain (N = 254) and Rude (N = 148), while the most commonly used two-word pairs were No/One (N = 27), Waste/Time (N = 25), and Severe/Pain (N = 18). In a multiple logistic regression, satisfactory reviews were associated with words such as Confident (odds ratio [OR] = 8.93), Pain-free (OR = 4.72), Listens (OR = 2.55), and Bedside Manner (OR = 1.70), while unsatisfactory reviews were associated with words such as Rude (OR = 0.01), Arrogant (OR = 0.09), Infection (OR = 0.20), and Wait (OR = 0.48). CONCLUSIONS: Female surgeons received significantly worse reviews and younger surgeons tended to receive better reviews. The positivity and negativity of reviews were largely related to words associated with the patient-doctor experience and pain. Vascular surgeons should focus on these 2 areas to improve patient experiences and their own reviews.

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.

Emerging Technologies in the Treatment of Adult Spinal Deformity.

Outcomes for adult spinal deformity continue to improve as new technologies become integrated into clinical practice. Machine learning, robot-guided spinal surgery, and patientspecific rods are tools that are being used to improve preoperative planning and patient satisfaction. Machine learning can be used to predict complications, readmissions, and generate postoperative radiographs which can be shown to patients to guide discussions about surgery. Robot-guided spinal surgery is a rapidly growing field showing signs of greater accuracy in screw placement during surgery. Patient-specific rods offer improved outcomes through higher correction rates and decreased rates of rod breakage while decreasing operative time. The objective of this review is to evaluate trends in the literature about machine learning, robot-guided spinal surgery, and patient-specific rods in the treatment of adult spinal deformity.

Music Augmented With Isochronic Auditory Beats or Vibrotactile Stimulation Does Not Affect Subsequent Ergometer Cycling Performance: A Pilot Study.

Methods to enhance the ergogenic effects of music are of interest to athletes of all abilities. The aim of this pilot study was to investigate the ergogenic effects of two commercially available methods of music augmentation: auditory beats and vibrotactile stimulation. Six male and five female cyclists/triathletes cycled for 7 minutes at three different intensities: a rate of perceived exertion (RPE) of 11 ("light"), RPE of 15 ("hard"), and a 7-minute time-trial. Before each 7-minute bout of cycling, participants listened to 10 minutes of self-selected music (MUS), or the same music with the addition of either isochronic auditory beats (ABS) or vibrotactile stimulation via SUBPACTM (VIB). MUS, ABS and VIB trials were performed in a randomized order. Power output was measured during cycling and felt arousal and feeling scores were recorded at timepoints throughout the protocol. The results found the augmented MUS interventions did not influence power output with no significant main effect of trial (p = 0.44, η2 = 0.09) or trial × cycling intensity interaction (p = 0.11, η2 = 0.20). Similarly, both felt arousal and feeling scores were unchanged between the MUS, ABS, and VIB trials (p > 0.05). In conclusion, this pilot study indicated an ineffectiveness of the ABS and VIB to affect subsequent 7-min cycling performance compared to self-selected MUS alone.