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1.
J Arthroplasty ; 35(2): 313-317.e1, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31601455

RESUMO

BACKGROUND: The majority of the cost analysis literature on total hip arthroplasties (THAs) has been focused around the perioperative and postoperative period, with preoperative costs being overlooked. METHODS: The Humana Administrative Claims database was used to identify Medicare Advantage (MA) and Commercial beneficiaries undergoing elective primary THAs. Preoperative healthcare resource utilization in the year prior to a THA was grouped into the following categories: office visits, X-rays, magnetic resonance imagings, computed tomography scans, intra-articular steroid and hyaluronic acid injections, physical therapy, and pain medications. Total 1-year costs and per-patient average reimbursements for each category have been reported. RESULTS: Total 1-year preoperative costs amounted to $21,022,883 (average = $512/patient) and $4,481,401 (average = $764/patient) for MA and Commercial beneficiaries, respectively. The largest proportion of total 1-year costs was accounted for by office visits (35% in Commercial; 41% in MA) followed by pain medications (28% in Commercial; 35% in MA). Conservative treatments (steroid injections, hyaluronic acid injections, physical therapy, and pain medications) alone accounted for 40%-44% of the total 1-year costs prior to a THA. A high healthcare utilization within the last 3 months prior to surgery was noted for opioids and steroid injections. CONCLUSION: On average, $500-$800/patient is spent on hip osteoarthritis-related care in the year prior to a THA. Despite their potential risks, opioids and steroid injections are often utilized in the last 3 months prior to surgery.

2.
Bone Joint J ; 101-B(12): 1570-1577, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31787005

RESUMO

AIMS: The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures. PATIENTS AND METHODS: Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses. RESULTS: A total of 98 769 patients were included; 35 701 patients were opioid-naïve, 11 621 used opioids continuously for six months before surgery, and 4558 used opioids continuously for at least six months but did not obtain any prescriptions in the three months before surgery. Among opioid-naïve patients, between 0.76% and 4.53% used opioids chronically postoperatively. Among chronic preoperative users, between 42% and 62% ceased chronic opioids postoperatively. A three-month opioid-free period preoperatively led to a rate of cessation of chronic opioid use between 82% and 93%, as compared with between 31% and 50% with continuous preoperative use (p < 0.001 for significant changes in opioid use before and after surgery in each procedure). Between 5.6 and 20.0 preoperative chronic users ceased chronic use for every new chronic opioid user. Risk factors for chronic postoperative use included chronic preoperative opioid use (odds ratio (OR) 4.84 to 39.75; p < 0.0001) and depression (OR 1.14 to 1.55; p < 0.05 except total hip arthroplasty). With a three-month opioid-free period before surgery, chronic preoperative opioids elevated the risk of chronic opioid use only mildly, if at all (OR 0.47 to 1.75; p < 0.05 for total shoulder arthroplasty, rotator cuff repair, and carpal tunnel release). CONCLUSION: Chronic preoperative opioid use increases the risk of chronic postoperative use, but an opioid-free period before surgery decreases this risk compared with continuous preoperative use Cite this article: Bone Joint J 2019;101-B:1570-1577.


Assuntos
Uso de Medicamentos/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos , Transtornos Relacionados ao Uso de Opioides/etiologia , Procedimentos Ortopédicos , Dor Pós-Operatória/tratamento farmacológico , Complicações Pós-Operatórias/etiologia , Bases de Dados Factuais , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Período Pré-Operatório , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco
3.
Clin Spine Surg ; 32(10): 435-438, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31609801

RESUMO

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To analyze risk factors associated with 30-day adverse outcomes and readmissions after revision anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: No current literature has evaluated the risk factors associated with adverse outcomes after revision ACDF. METHODS: The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using Current Procedural Terminology codes for ACDF (22551, 22554, and 63075) combined with Current Procedural Terminology codes 22830 (exploration of spinal fusion) or 22855 (removal of anterior instrumentation) to identify revision cases. Patients undergoing concurrent posterior cervical spine surgery and/or corpectomies were excluded from the analysis. A total of 1140 patients were retrieved for analysis. RESULTS: Out of a total of 1140 patients, 51 (4.5%) experienced at least 1 any adverse event, with 40 (3.5%) experiencing a severe adverse event, and 17 (1.5%) experiencing a minor adverse event. A 30-day readmission rate was 3.4% (N=39) after a revision ACDF. On multivariate analysis, any adverse events were significantly associated with male sex [odds ratio (OR), 1.98], 2-level versus 1-level fusion (OR, 2.05), and a length of stay (LOS)>1 day (OR, 7.70). Severe adverse events were independently associated with male sex (OR, 2.85), smoking (OR, 0.33), 2-level versus 1-level fusion (OR, 2.03), and LOS>1 day (OR, 7.28). LOS>1 day was the only significant factor associated with an minor adverse event (OR, 14.65) and readmission within 30 days (OR, 2.67). CONCLUSIONS: Using a national surgical database, the study is the first of its kind to report rates and risk factors associated with adverse outcomes after ACDFs. Providers should understand the need of preoperative risk stratification in these patients to reduce the risk of experiencing adverse outcomes. LEVEL OF EVIDENCE: Level III-retrospective.

4.
Surgery ; 166(4): 489-495, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31326186

RESUMO

BACKGROUND: Emergency general surgery can have a profound impact on the functional status of even previously independent patients. The role and influence of discharging a patient to a skilled nursing facility, however, remains largely unknown. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program for community-dwelling adults who underwent 1 of 7 emergency general surgery procedures and were discharged home or to a skilled nursing facility from 2012 to 2016. Propensity score matching and multivariable regression analyses were performed to determine the relationship between discharge disposition and outcomes. RESULTS: Overall, 140,922 patients met the inclusion criteria. The majority were discharged home (95.9%). After applying 1:1 propensity score matching, in comparison to patients discharged home, individuals discharged to a skilled nursing facility had a greater odds of respiratory (odds ratio 2.32; 95% confidence interval, 1.59-3.38) and septic complications (odds ratio 1.63, 95% confidence interval 1.12-2.36) after discharge. Furthermore, following surgery, individuals discharged to a skilled nursing facility had a greater odds of 30-day readmission (odds ratio 1.14; 95% confidence interval, 1.01-1.29), and death within 30 days of the procedure (odds ratio 2.07; 95% confidence interval, 1.65-2.61). CONCLUSION: After accounting for patient severity and perioperative course, discharge to a skilled nursing facility is an independent risk factor for death, readmission, and postdischarge complications.


Assuntos
Emergências , Cirurgia Geral/métodos , Serviços de Assistência Domiciliar/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Vida Independente , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Análise de Sobrevida , Estados Unidos
5.
Clin Spine Surg ; 32(7): 285-294, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30839422

RESUMO

STUDY DESIGN: Systematic review. OBJECTIVE: To assess the impact of hospital volume on postoperative outcomes in spine surgery. SUMMARY OF BACKGROUND DATA: Several strategies have recently been proposed to optimize provider outcomes, such as regionalization to higher volume centers and setting volume benchmarks. MATERIALS AND METHODS: We performed a systematic review examining the association between hospital volume and spine surgery outcomes. To be included in the review, the study population had to include patients undergoing a primary or revision spinal procedure. These included anterior/posterior cervical fusions, anterior/posterior lumbar fusions, laminectomies, discectomies, spinal deformity surgeries, and surgery for spinal malignancies. We searched the Pubmed, OVID MEDLINE (1966-2018), Google Scholar, and Web of Science (1900-2018) databases in January 2018 using the search criteria ("Hospital volume" OR "volume" OR "volume-outcome" OR "volume outcome") AND ("spine" OR "spine surgery" OR "lumbar" OR "cervical" OR "decompression" OR "deformity" OR "fusions"). There were no restrictions placed on study design, publication date, or language. The studies were evaluated with respect to the quality of methodology as outlined by the Grading of Recommendations Assessment, Development, and Evaluation system. RESULTS: Twelve studies were included in the review. Studies were variable in defining hospital volume thresholds. Higher hospital volume was associated with statistically significant lower risks of postoperative complications, a shorter length of stay, lower cost of hospital stay, and a lower risk of readmissions and reoperations/revisions. CONCLUSIONS: Our findings suggest a trend toward better outcomes for higher volume hospitals; however, further study needs to be carried out to define objective volume thresholds for specific spine surgeries for hospitals to use as a marker of proficiency.

6.
J Pediatr Orthop B ; 28(2): 167-172, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30204625

RESUMO

Clubfoot is an important aspect of pediatric orthopedics and is a readily prevalent condition presenting to orthopedic clinics worldwide. To identify landmark articles and important contributions to this field, we sought to do a citation analysis of the top 100 most-cited articles on clubfoot. Using the Scopus database and the search strategy 'Clubfoot', 'Clubfeet' OR 'Talipes Equinovarus', we identified 5753 articles. After filtering for relevant articles, the top 100 cited articles on clubfoot were retrieved for descriptive and statistical analysis. The most cited paper was 'Long-term results of treatment of congenital clubfoot' by S.J. Laaveg and I.V. Ponseti with 358 citations. The publication years ranged from 1969 to 2011. The USA was the most productive country in terms of research output, followed by the UK. Institution-wise, the University of Iowa contributed the most in terms of number of publications. The Journal of Pediatric Orthopaedics held the most number of articles. Most publications were level IV and level V studies. Although citation analysis has it flaws, this is a comprehensive list of the top 100 articles significantly affecting literature on clubfoot. On the basis our study, we conclude that there is marked deficiency of high-level articles with respect to the number of citations, and future researches need to cater to this question to produce high-quality studies.


Assuntos
Pé Torto Equinovaro , Bases de Dados Factuais/tendências , Revisão por Pares/tendências , Publicações Periódicas como Assunto/tendências , Pé Torto Equinovaro/epidemiologia , Pé Torto Equinovaro/terapia , Humanos
7.
Clin Spine Surg ; 31(9): E453-E459, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30067516

RESUMO

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The main objective of this article was to investigate the impact of discharge destination on postdischarge outcomes following an elective 1- to 2-level posterior lumbar fusion (PLF) for degenerative pathology. BACKGROUND DATA: Discharge to an inpatient care facility may be associated with adverse outcomes as compared with home discharge. MATERIALS AND METHODS: The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to query for patients undergoing PLFs using Current Procedural Terminology (CPT) codes (22612, 22630, and 22633). Additional levels were identified using CPT-22614, CPT-22632, and CPT-22634. Records were filtered to include patients undergoing surgery for degenerative spine pathologies. Only patients undergoing a single-level or 2-level PLF were included in the study. A total of 23,481 patients were included in the final cohort. RESULTS: A total of 3938 (16.8%) patients were discharged to a skilled care or rehabilitation facility following the primary procedure. Following adjustment for preoperative, intraoperative, and predischarge clinical characteristics, discharge to a skilled care or rehabilitation facility was associated with higher odds of any complication [odds ratio (OR), 1.70; 95% confidence interval (CI), 1.43-2.02], wound complications (OR, 1.73; 95% CI, 1.36-2.20), sepsis-related complications (OR, 1.64; 95% CI, 1.08-2.48), deep venous thrombosis/pulmonary embolism complications (OR, 1.72; 95% CI, 1.10-2.69), urinary tract infections (OR, 1.96; 95% CI, 1.45-2.64), unplanned reoperations (OR, 1.49; 95% CI, 1.23-1.80), and readmissions (OR, 1.29; 95% CI, 1.10-1.49) following discharge. CONCLUSIONS: After controlling for predischarge characteristics, discharge to skilled care or rehabilitation facilities versus home following 1- to 2-level PLF is associated with higher odds of complications, reoperations, and readmissions. These results stress the importance of careful patient selection before discharge to inpatient care facilities to minimize the risk of complications. Furthermore, the results further support the need for uniform and standardized care pathways to promote home discharge following hospitalization for elective PLFs. LEVEL OF EVIDENCE: Level III.


Assuntos
Procedimentos Cirúrgicos Eletivos , Pacientes Internados , Vértebras Lombares/cirurgia , Alta do Paciente , Readmissão do Paciente , Complicações Pós-Operatórias/etiologia , Fusão Vertebral/efeitos adversos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Resultado do Tratamento
8.
J Arthroplasty ; 33(10): 3329-3342, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29921502

RESUMO

BACKGROUND: Surgeon volume has been identified as an important factor impacting postoperative outcome in patients undergoing orthopedic surgeries. With an absence of a detailed systematic review, we sought to collate evidence on the impact of surgeon volume on postoperative outcomes in patients undergoing primary total hip arthroplasty. METHODS: PubMed (MEDLINE) and Google Scholar databases were queried for articles using the following search criteria: ("Surgeon Volume" OR "Provider Volume" OR "Volume Outcome") AND ("THA" OR "Total hip replacement" OR "THR" OR "Total hip arthroplasty"). Studies investigating total hip arthroplasty being performed for malignancy or hip fractures were excluded from the review. Twenty-eight studies were included in the final review. All studies underwent a quality appraisal using the GRADE tool. The systematic review was performed in accordance with the PRISMA guidelines. RESULTS: Increasing surgeon volume was associated with a shorter length of stay, lower costs, and lower dislocation rates. Studies showed a significant association between an increasing surgeon volume and higher odds of early-term and midterm survivorship, but not long-term survivorships. Although complications were reported and recorded differently in studies, there was a general trend toward a lower postoperative morbidity with regard to complications following surgeries by a high-volume surgeon. CONCLUSION: This systematic review shows evidence of a trend toward better postoperative outcomes with high-volume surgeons. Future prospective studies are needed to better determine long-term postoperative outcomes such as survivorship before healthcare policies such as regionalization and/or equal-access healthcare systems can be considered.


Assuntos
Artroplastia de Quadril/mortalidade , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Artroplastia de Quadril/efeitos adversos , Humanos , Ortopedia , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Resultado do Tratamento
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