Profit-Influencing Factors in Orthopedic Surgery: An Analysis of Costs and Reimbursements.

The aging population and the associated demand for orthopedic surgeries are increasing health costs. Although the Diagnostic Related Groups (DRG) system was introduced to offer incentives for hospitals, concerns remain that reimbursements for older and frail patients do not cover all hospital expenses. We investigated further: (1) Does age influence net financial results in orthopedic surgery? (2) Are there patient or surgical factors that influence results? This retrospective, monocentric study compares costs and reimbursements for orthopedic patients in a tertiary care hospital in Switzerland between 2015 and 2017. The data of 1230 patients were analyzed. Overall, the net results for the hospital were positive, despite 19.5% of patients being treated at a loss. We did not find any correlation between age and profitability (p = 0.61). Patient-related factors associated with financial losses were female sex (p < 0.001) and diabetes (p = 0.013). Patients free of serious comorbidities (p = 0.012) or with a higher cost weight (p < 0.001) were more often profitable. A longer length of stay was associated with higher losses (p < 0.001). This is the first study to address the Swiss DRG reimbursement system in a broad orthopedic population, while also analyzing specific patient and surgical factors. Overall, the reimbursement system is fair, but could better account for certain interventions.

CD25 as a unique marker on human basophils in stable-mildly symptomatic allergic asthma.

Background: Basophils in acute asthma exacerbation are activated as evidenced by their increased expression levels of activation markers such as CD203c and CD63. However, whether basophils of allergic asthmatics who are in stable phase and have no asthma exacerbations display a specific and distinctive phenotype from those of healthy individuals has yet to be well characterized. Objective: We aimed to identify the phenotype of basophils from allergic asthmatics in the stable phase and investigate whether such a phenotype is affected by ex vivo allergen stimulation. Methods: We determined by flow cytometry, the expression of surface proteins such as CD25, CD32, CD63, CD69, CD203c, and CD300a and intracellular anti-apoptotic proteins BCL-2, BCL-xL, and MCL-1. We investigated these markers in blood basophils obtained from well-characterized patients with stable-mildly symptomatic form of allergic asthma with no asthma exacerbation and from healthy individuals. Moreover, we determined ex vivo CD63, CD69, and CD25 on blood basophils from stable-mildly symptomatic allergic asthmatics upon allergen stimulation. Results: In contrast to all tested markers, CD25 was significantly increased on circulating basophils in the patient cohort with stable-mildly symptomatic allergic asthma than in healthy controls. The expression levels of CD25 on blood basophils showed a tendency to positively correlate with FeNO levels. Notably, CD25 expression was not affected by ex vivo allergen stimulation of blood basophils from stable-mildly symptomatic allergic asthma patients. Conclusion: Our data identifies CD25 as a unique marker on blood basophils of the stable phase of allergic asthma but not of asthma exacerbation as mimicked by ex vivo allergen stimulation.

Readmissions after elective orthopedic surgery in a comprehensive co-management care system-a retrospective analysis.

BACKGROUND: No surgical intervention is without risk. Readmissions and reoperations after elective orthopedic surgery are common and are also stressful for the patient. It has been shown that a comprehensive ortho-medical co-management model decreases readmission rates in older patients suffering from hip fracture; but it is still unclear if this also applies to elective orthopedic surgery. The aim of the current study was to determine the proportion of unplanned readmissions or returns to operating room (for any reason) across a broad elective orthopedic population within 90 days after elective surgery. All cases took place in a tertiary care center using co-management care and were also assessed for risk factors leading to readmission or unplanned return to operating room (UROR). METHODS: In this observational study, 1295 patients undergoing elective orthopedic surgery between 2015 and 2017 at a tertiary care center in Switzerland were investigated. The proportion of reoperations and readmissions within 90 days was measured, and possible risk factors for reoperation or readmission were identified using logistic regression. RESULTS: In our cohort, 3.2% (42 of 1295 patients) had an UROR or readmission. Sixteen patients were readmitted without requiring further surgery-nine of which due to medical and seven to surgical reasons. Patient-related factors associated with UROR and readmission were older age (67 vs. 60 years; p = 0.014), and American Society of Anesthesiologists physical status (ASA PS) score ≥ 3 (43% vs. 18%; p < 0.001). Surgery-related factors were: implantation of foreign material (62% vs. 33%; p < 0.001), duration of operation (76 min. vs. 60 min; p < 0.001), and spine surgery (57% vs. 17%; p < 0.001). Notably, only spine surgery was also found to be independent risk factor. CONCLUSION: Rates of UROR during initial hospitalization and readmission were lower in the current study than described in the literature. However, several comorbidities and surgery-related risk factors were found to be associated with these events. Although no surgery is without risk, known threats should be reduced and every effort undertaken to minimize complications in high-risk populations. Further prospective controlled research is needed to investigate the potential benefits of a co-management model in elective orthopedic surgery.

Prolonged antibiotic prophylaxis use in elective orthopaedic surgery - a cross-sectional analysis.

PURPOSE: Surgical antibiotic prophylaxis (SAP) prevents surgical site infections (SSI). In orthopaedic surgery, the use of prolonged SAP (PSAP) has been reported in daily routine, despite guidelines advising against it. Therefore, we asked: What is the proportion of PSAP use, defined as administration of SAP ≥24 h after elective orthopaedic surgery? Are there patient- and surgery-related predictors of PSAP use? METHODS: This cross-sectional analysis investigated 1292 patients who underwent elective orthopaedic surgery including total joint arthroplasties at one Swiss centre between 2015 and 2017. Patient comorbidities, surgical characteristics and occurrence of SSI at 90 days in PSAP group were compared to the SAP group (< 24 h post-operative). RESULTS: PSAP use was 12% (155 of 1292). Patient-related factors associated with PSAP compared to the SAP group included older age (63 vs. 58y; p < 0.001), higher BMI (29 vs. 27 kg/m2; p < 0.001), ASA classification ≥3 (31% vs. 17%; p < 0.001) and lung disease (17% vs. 9%; p = 0.002). Surgery-related factors associated with PSAP were use of prosthetics (62% vs. 45%; p < 0.001), surgery of the knee (65% vs. 25%; p < 0.001), longer surgery duration (87 vs. 68 min; p < 0.001) and presence of drains (90% vs. 65%; p < 0.001). All four SSI occurred in the SAP group (0 vs. 4; p = 1.0). Surgeons administered PSAP with varying frequencies; proportions ranged from 0 to 33%. CONCLUSION: PSAP use and SSI proportions were lower than reported in the literature. Several patient- and surgery-related factors associated with PSAP use were identified and some were potentially modifiable. Also, experienced surgeons seemed to implement differing approaches regarding the duration of SAP administration.

Preoperative decolonization and periprosthetic joint infections-A randomized controlled trial with 2-year follow-up.

Preoperative decolonization, especially of Staphylococcus aureus carriers, has been proposed to reduce periprosthetic joint infections (PJI), but the evidence-based consensus is still lacking and data on long-term outcomes is scarce. In a previous randomized, single-blinded trial, decolonization produced no significant reduction of surgical site infections in overall elective orthopedic surgery at 3-month follow-up. A 2-year follow-up was then performed to specifically detect the impact of decolonization on delayed-onset PJI (3-24 months after surgery). Between November 2015 and September 2017, 613 of 1318 recruited patients underwent prosthetic surgery. Individuals were allocated into either the S. aureus carrier group (34%, 207 of 613 patients) or the noncarrier group (406 of 613 patients), according to nasal swab screening results. Both groups were then randomized into intervention and control arms. In the S. aureus group, the intervention consisted of daily chlorhexidine showers and application of mupirocin nasal ointment twice a day for 5 days before surgery. In noncarriers, only chlorhexidine showers were prescribed. Sample size calculation was based on the initial trial for overall and not for the prosthetic surgery group. No PJI was found at 2 years in either the carrier or in the noncarrier group. Therefore, no definite conclusion about the efficacy of preoperative decolonization to reduce PJI can be drawn. PJI proportions in this study were lower than described in the literature (mostly around 0.3%). Despite the insufficient sample size, this trial is the largest randomized trial on decolonization with a long-term follow-up, and results may be helpful for future meta-analyses.

Does Preoperative Decolonization Reduce Surgical Site Infections in Elective Orthopaedic Surgery? A Prospective Randomized Controlled Trial.

BACKGROUND: Surgical site infections (SSIs) after elective orthopaedic surgery are very stressful for patients due to frequent rehospitalizations with reoperations and poorer functional outcomes. Prevention of such events is therefore crucial. Although an evidence-based consensus is still lacking, preoperative decolonization could decrease SSI. Specifically, more information is needed about the effect of a preoperative decolonization procedure on SSI proportions in both Staphylococcus aureus carriers and non-S. aureus carriers after general orthopaedic surgery. QUESTIONS/PURPOSES: Our study addressed the following questions: (1) Does preoperative decolonization reduce the risk of SSI after general elective orthopaedic surgery in patients colonized with S. aureus? (2) Does preoperative decolonization reduce the risk of SSI among patients who are not colonized with S. aureus? METHODS: In this prospective, randomized, single-blinded trial, we recruited patients undergoing general elective orthopaedic surgery in one tertiary care center in Switzerland. Between November 2014 and September 2017, 1318 of 1897 screened patients were enrolled. Patients were allocated into either the S. aureus carrier group (35%, 465 of 1318 patients) or the noncarrier group (65%, 853 of 1318 patients) according to screening culture results. In the S. aureus group, 232 patients were allocated to the intervention arm and 233 were allocated to the control arm. Intervention was 5 days of daily chlorhexidine showers and mupirocin nasal ointment twice a day. Of the 853 noncarriers, 426 were allocated to the intervention arm and 427 were allocated to the control arm. All patients in both groups were analyzed in an intention-to-treat manner. The primary endpoint was SSI occurrence at 90 days postoperative and the secondary endpoint was SSI occurrence at 30 days postoperative.The initial sample size calculation was made for the S. aureus carrier group. Based on the literature review, a 4% proportion of SSI was expected in the control group. Thus, 726 carriers would have been needed to detect a relative risk reduction of 80% with a power of 80% at a two-sided α-error of 0.048 (adjusted for interim analysis). Assuming carrier prevalence of 27%, 2690 patients would have been needed in total. An interim analysis was performed after including half of the targeted S. aureus carriers (363 of 726). Based on the low infection rate in the control group (one of 179), a new sample size of 15,000 patients would have been needed. This was deemed not feasible and the trial was stopped prematurely. RESULTS: Among carriers, there was no difference in the risk of SSI between the intervention and control arms (decolonized SSI risk: 0.4% [one of 232], control SSI risk: 0.4% [one of 233], risk difference: 0.0% [95% CI -1.2% to 1.2%], stratified for randomization stratification factors; p > 0.999). For noncarriers, there was no difference in risk between the intervention and control arms (decolonized SSI risk: 0.2% [one of 426], control SSI risk: 0.2% [one of 247], stratified risk difference: -0.0% [95% CI -0.7 to 0.6]; p = 0.973). CONCLUSIONS: We found no difference in the risk of SSI between the decolonization and control groups, both in S. aureus carriers and noncarriers. Because of the low event numbers, no definite conclusion about efficacy of routine preoperative decolonization can be drawn. The results, however, may be helpful in future meta-analyses. LEVEL OF EVIDENCE: Level II, therapeutic study.

A mouse model for SPG48 reveals a block of autophagic flux upon disruption of adaptor protein complex five.

Hereditary spastic paraplegia is a spastic gait disorder that arises from degeneration of corticospinal axons. The subtype SPG48 is associated with mutations in the zeta subunit of the adaptor protein complex five (AP5). AP5 function and the pathophysiology of SPG48 are only poorly understood. Here, we report an AP5 zeta knockout mouse, which shows an age-dependent degeneration of corticospinal axons. Our analysis of knockout fibroblasts supports a trafficking defect from late endosomes to the transGolgi network and reveals a structural defect of the Golgi. We further show that both autophagic flux and the recycling of lysosomes from autolysosomes were impaired in knockout cells. In vivo, we observe an increase of autophagosomes and autolysosomes and, at later stages, the accumulation of intracellular waste in neurons. Taken together, we propose that loss of AP5 function blocks autophagy and thus leads to the aberrant accumulation of autophagic cargo, which finally results in axon degeneration.