Registry Data Show Complication Rates and Cost in Revision Hip Arthroplasty.

BACKGROUND: Revision total hip arthroplaty (rTHA) places a burden on patients, surgeons, and health care systems because outcomes and costs are less predictable than primary THA. The purpose of this study was to define indications and treatments for rTHA, quantify risk for readmissions, and evaluate the economic impacts of rTHA in a hospital system. METHODS: The arthroplasty database of a hospital system was queried to generate a retrospective cohort of 793 rTHA procedures, performed on 518 patients, from 2017 to 2019 at 27 hospitals. Surgeons performed chart reviews to classify indication and revision procedure. Demographics, lengths of stay, discharge dispositions, and readmission data were collected. Analyses of direct costs were performed and categorized by revision type. RESULTS: Totally, 46.3% of patients presented for infection. Patients presenting for infection were 5.6 times more likely to have repeat rTHA than aseptic patients. Septic cases (4.3 days) had longer length of stay than aseptic ones (2.4) (P < .0001). However, 31% of patients discharged to a skilled nursing facility. Direct costs were greatest for a two-stage exchange ($37,642) and lowest for liner revision ($8,979). Septic revisions ($17,696) cost more than aseptic revisions ($11,204) (P < .0001). The 90-day readmission rate was 21.8%. Septic revisions had more readmissions (13.5%) than aseptic revisions (8.3%). CONCLUSIONS: Hip revisions, especially for infection, have an increased risk profile and create a major economic impact on hospital systems. Surgeons may use these data to counsel patients on risks of rTHA and advocate for improved reimbursement for the care of revision patients.

Robotic Versus Manual Total Knee Arthroplasty in High Volume Surgeons: A Comparison of Cost and Quality Metrics.

BACKGROUND: Robotic-assisted total knee arthroplasty (RTKA) was introduced to improve surgical accuracy and patient outcomes. However, RTKA may also increase operating time and add cost to TKA. This study sought to compare the differences in cost and quality measures between manual TKA (MTKA) and RTKA METHODS: All MTKAs and RTKAs performed between January 1, 2017 and December 31, 2019, by 6 high volume surgeons in each cohort, were retrospectively reviewed. Cohorts were propensity score matched. Operative time, length of stay (LOS), total direct cost, 90-day complications, utilization of postacute services, and 30-day readmissions were studied. RESULTS: After one-to-one matching, 2392 MTKAs and 2392 RTKAs were studied. In-room/out-of-room operating time was longer for RTKA (139 minutes) than for MTKA (107 minutes) P < .0001, as was procedure time (RTKA 78 minutes; MTKA 70 minutes), P < .0001. Median LOS was equal for MTKA and RTKA (33 hours). Total cost per case was greater for RTKA ($11,615) than MTKA ($8674), P < .0001. Home health care was utilized more frequently after RTKA (38%) than MTKA (29%), P < .0001. There was no significant difference in 90-day complication rates. Thirty-day readmissions occurred more often after MTKA (4.9%) than RTKA (1.2%), P < .0001. CONCLUSION: RTKA was a longer and costlier procedure than MTKA for experienced surgeons, without clinically significant differences in LOS or complications. Home health care was utilized more often after RTKA, but fewer readmissions occurred after RTKA. Longer term follow-up and functional outcome studies are required to determine if the greater cost of RTKA is offset by lower revision rates and/or improved functional results.

Major disparities in COVID-19 test positivity for patients with non-English preferred language even after accounting for race and social factors in the United States in 2020.

BACKGROUND: The COVID-19 pandemic has further exposed inequities in our society, demonstrated by disproportionate COVID-19 infection rate and mortality in communities of color and low-income communities. One key area of inequity that has yet to be explored is disparities based on preferred language. METHODS: We conducted a retrospective cohort study of 164,368 adults tested for COVID-19 in a large healthcare system across Washington, Oregon, and California from March - July 2020. Using electronic health records, we constructed multi-level models that estimated the odds of testing positive for COVID-19 by preferred language, adjusting for age, race/ethnicity, and social factors. We further investigated interaction between preferred language and both race/ethnicity and state. Analysis was performed from October-December 2020. RESULTS: Those whose preferred language was not English had higher odds of having a COVID-19 positive test (OR 3.07, p < 0.001); this association remained significant after adjusting for age, race/ethnicity, and social factors. We found significant interaction between language and race/ethnicity and language and state, but the odds of COVID-19 test positivity remained greater for those whose preferred language was not English compared to those whose preferred language was English within each race/ethnicity and state. CONCLUSIONS: People whose preferred language is not English are at greater risk of testing positive for COVID-19 regardless of age, race/ethnicity, geography, or social factors - demonstrating a significant inequity. Research demonstrates that our public health and healthcare systems are centered on English speakers, creating structural and systemic barriers to health. Addressing these barriers are long overdue and urgent for COVID-19 prevention.

Randomised comparison of techniques for control of the dorsal venous complex during robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: To prospectively compare the effects of endoscopic stapling, division and suture ligation, and suture ligation with suspension of the dorsal venous complex (DVC) on continence during robot-assisted laparoscopic radical prostatectomy (RARP). PATIENTS AND METHODS: In all, 300 consecutive patients undergoing RARP by a single surgeon were randomised to three groups: endoscopic stapling, cut and suture ligation, and suture ligation with suspension. The only difference between the groups was the technique to control the DVC. Pad-free continence (PFC) and overall continence (0 pads/day with or without security pad) were assessed with patient reported pad usage records and validated questionnaires (Expanded Prostate Cancer Index) at 3, 12, and 15 months. Secondary endpoints were erectile function (EF) recovery (defined as erections sufficient for sexual activity) and the rate of apical surgical margins. Univariate and multivariate analyses were conducted to determine predictors for recovery of both urinary continence and EF. RESULTS: The three groups were comparable in terms of age, body mass index, prostate size, American Urological Association symptom score, Sexual Health Inventory for Men, and clinical stage. There were no differences found in terms of operative times, estimated blood loss, pathological stage, and positive apical margin. There was no difference between the three groups with regard to overall continence or PFC at 3 months. However, overall continence at 15 months for ligation and suspension was 99% and was superior to stapler (88%) (P = 0.002) and cut and suture ligation (88%) (P = 0.002). Additionally, PFC at 15 months was superior for ligation and suspension (87%) as compared to stapler (73%) and cut and suture ligation (75%) (P = 0.045). The technique of DVC control did not impact EF. Men with nerve sparing had better continence compared to no nerve sparing at 3 months (62% vs 42%, P = 0.045), but not at 15 months. The median time to continence was 2 months for patients receiving nerve sparing compared to 4.5 months for non-nerve sparing (P = 0.02). CONCLUSION: Suture suspension of the DVC during RARP contributes to higher overall continence rates compared to stapling and cut and suture. Nerve sparing contributes to earlier return of continence than non-nerve sparing.

Transperitoneal vs. retroperitoneal robotic partial nephrectomy: a matched-paired analysis.

PURPOSE: When performing robotic nephron-sparing surgery (NSS) for renal tumors, either a transperitoneal approach or retroperitoneal approach can be utilized. The operative technique for robotic retroperitoneal partial nephrectomy (RPPN) is discussed and a matched-paired analysis comparing both RPPN and transperitoneal partial nephrectomy (TPPN) at a single institution is discussed. MATERIALS AND METHODS: A retrospective review over a 10-year period (2006-2016) was performed for all patients who underwent robotic partial nephrectomy. A total of 281 patients underwent RPPN and 263 patients underwent TPPN. A matched-paired analysis was performed on 166 pairs of patients and the outcomes reviewed. RESULTS: Operative time (p < 0.001) and estimated blood loss (p < 0.001) were significantly less in the RPPN group compared to the TPPN group. No differences (p > 0.05) were seen with regard to complexity of cases, warm ischemia time, tumor pathology, positive margin rates, complications, or kidney function post-operatively. CONCLUSIONS: Robotic RPPN and TPPN can both be used for NSS with good results. RPPN, when used appropriately, can lead to shorter operative times, less blood loss and equivalent oncologic and post-operative outcomes. Surgeon comfort and expertise will help determine which approach to use.

Increasing and Retaining African Surgeons Working in Rural Hospitals: An Analysis of PAACS Surgeons with Twenty-Year Program Follow-Up.

BACKGROUND: African surgical workforce needs are significant, with largest disparities existing in rural settings. Pan-African Academy of Christian Surgeons (PAACS), a primarily rural-based general surgery training program, has published successes in producing rural African surgeons; however, long-term follow-up data are unreported. The goal of our study was to define characteristics of PAACS alumni surgeons working in rural hospitals, documenting successes and illuminating strategies for trainee recruitment and retention. METHOD: PAACS' twenty-year surgery residency database was reviewed for 12 programs throughout Africa regarding trainee demographics and graduate outcomes. Characteristics of PAACS' graduate surgeons were further analyzed with a 42-question survey. RESULTS: Among active PAACS graduates, 100% practice in Africa and 79% within their home country. PAACS graduates had 51% short-term and 35% long-term (beyond 5 years) rural retention rate (less than 50,000 population). CONCLUSION: Our study shows that PAACS general surgery training program has a high retention rate of African surgeons in rural settings compared to all programs reported to date, highlighting a multifaceted, rural-focused approach that could be emulated by surgical training programs worldwide.

What does Medicaid expansion mean for cancer screening and prevention? Results from a randomized trial on the impacts of acquiring Medicaid coverage.

BACKGROUND: The Oregon Medicaid lottery provided a unique opportunity to assess the causal impacts of health insurance on cancer screening rates within the framework of a randomized controlled trial. Prior studies regarding the impacts of health insurance have almost always been limited to observational evidence, which cannot be used to make causal inferences. METHODS: The authors prospectively followed a representative panel of 16,204 individuals from the Oregon Medicaid lottery reservation list, collecting data before and after the Medicaid lottery drawings. The study panel was divided into 2 groups: a treatment group of individuals who were selected in the Medicaid lottery (6254 individuals) and a control group who were not (9950 individuals). The authors also created an elevated risk subpanel based on family cancer histories. One year after the lottery drawings, differences in cancer screening rates, preventive behaviors, and health status were compared between the study groups. RESULTS: Medicaid coverage resulted in significantly higher rates of several common cancer screenings, especially among women, as well as better primary care connections and self-reported health outcomes. There was little evidence found that acquiring Medicaid increased the adoption of preventive health behaviors that might reduce cancer risk. CONCLUSIONS: Medicaid coverage did not appear to directly impact lifestyle choices that might reduce cancer risk, but it did provide access to important care and screenings that could help to detect cancers earlier. These findings could have long-term population health implications for states considering or pursuing Medicaid expansion. Cancer 2016;122:791-797. © 2015 American Cancer Society.

The incidence and prevalence of temporomandibular disorders and posterior open bite in patients receiving mandibular advancement device therapy for obstructive sleep apnea.

PURPOSE: This study aims to evaluate the incidence and prevalence of temporomandibular disorders (TMD) in patients receiving a mandibular advancement device (MAD) to treat obstructive sleep apnea using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). In addition, it also aims to assess the development of posterior open bite (POB). MATERIALS AND METHODS: Data from 167 patients were evaluated at baseline, from 159 patients after 118 days (visit II), from 129 patients after 208 days (visit III), and from 85 patients after 413 days (visit IV). The presence of TMD symptoms was evaluated through a questionnaire. TMD signs were assessed using the RDC/TMD. Clinical evaluation assessed for the presence of POB. RESULTS: The prevalence of TMD was 33/167 (19.8 %) at baseline. After an initial decrease to 14.5 % on visit II, the prevalence increased to 19.4 % on visit III and finally demonstrated a decrease to 8.2 % on visit IV. The incidence of TMD was 10.6 % on visit II. This decreased on further visits and only two (1.9 %) patients developed TMD from visit III to visit IV. POB was found to develop with an average incidence of 6.1 % per visit. The prevalence of POB was 5.8 % on visit II, 9.4 % on visit III, and 17.9 % on visit IV. CONCLUSION: The use of MADs may lead to the development of TMD in a small number of patients. Nevertheless, these signs are most likely transient. Patients with pre-existing signs and symptoms of TMD do not experience significant exacerbation of those signs and symptoms with MAD use. Furthermore, these may actually decrease over time. POB was found to develop in 17.9 % of patients; however, only 28.6 % of these patients were aware of any bite changes.

Brief training in ultrasound equips novice clinicians to accurately and reliably measure jugular venous pressure in obese patients.

Introduction/Purpose: Measurement of jugular venous pressure (JVP) by novice clinicians can be unreliable, particularly when evaluating obese patients. Measurement of JVP using ultrasound (uJVP) is simple to perform and provides accurate measurements. This study evaluated whether students and residents inexperienced with ultrasound could rapidly be taught to measure JVP using ultrasound in obese patients with the same accuracy as cardiologists measuring JVP via physical examination. Additionally, this study also evaluated the correlation between qualitative and quantitative JVP assessment. Methods: This prospective, blinded study compared uJVP measurements performed by novice clinicians after brief training to JVP measurements performed by cardiologists (cJVP) on physical examination. Association between uJVP and cJVP was assessed using linear correlation, agreement and bias were assessed using the Bland-Altman analysis and inter-rater reliability of uJVP was assessed using intraclass correlation coefficient (ICC). The association between qualitative and quantitative JVP assessment was assessed using linear correlation. Results: Novice clinicians (n = 16) obtained 34 measurements from 26 patients (mean BMI 35.5) and reported moderate-to-high confidence in all measurements. uJVP correlated well with cJVP (r = 0.73) with an average error of 0.06 cm. The estimated uJVP ICC was 0.83 (95% CI = 0.44, 0.96). Qualitative uJVP had only a moderate correlation (r = 0.63) to quantitative uJVP. Discussion: Novice clinicians often have difficulty assessing JVP on physical examination, particularly in obese patients. Our findings show a high degree of correlation between JVP measurements performed by novice clinicians using ultrasound compared with JVP measurements made by experienced cardiologists on physical examination. Furthermore, novice clinicians were able to be trained quickly, their measurements were determined to be accurate and precise and they expressed moderate-to-high confidence in their results. Conclusions: After brief training, novice clinicians were able to accurately assess JVP in obese patients as compared to measurements made by experienced cardiologists on physical examination. Results suggest that ultrasound may greatly improve novice clinicians' JVP assessment accuracy, particularly in obese patients.

Discordance Between Standard Equations for Determination of LDL Cholesterol in Patients With Atherosclerosis.

BACKGROUND: Accurate estimation of low-density lipoprotein cholesterol (LDL-C) is important for guiding cholesterol-lowering therapy. Different methods currently exist to estimate LDL-C. OBJECTIVES: This study sought to assess discordance of estimated LDL-C using the Friedewald, Sampson, and Martin/Hopkins equations. METHODS: Electronic health record data from patients with atherosclerotic cardiovascular disease and triglyceride (TG) levels of <400 mg/dL between October 1, 2015, and June 30, 2019, were retrospectively analyzed. LDL-C was estimated using the Friedewald, Sampson, and Martin/Hopkins equations. Patients were categorized as concordant if LDL-C was <70 mg/dL with each pairwise comparison of equations and as discordant if LDL-C was <70 mg/dL for the index equation and ≥70 mg/dL for the comparator. RESULTS: The study included 146,106 patients with atherosclerotic cardiovascular disease (mean age: 68 years; 56% male; 91% White). The Martin/Hopkins equation consistently estimated higher LDL-C values than the Friedewald and Sampson equations. Discordance rates were 15% for the Friedewald vs Martin/Hopkins comparison, 9% for the Friedewald vs Sampson comparison, and 7% for the Sampson vs Martin/Hopkins comparison. Discordance increased at lower LDL-C cutpoints and in those with elevated TG levels. Among patients with TG levels of ≥150 mg/dL, a >10 mg/dL difference in LDL-C was present in 67%, 27%, and 23% of patients when comparing the Friedewald vs Martin/Hopkins, Friedewald vs Sampson, and Sampson vs Martin/Hopkins equations, respectively. CONCLUSIONS: Clinically meaningful differences in estimated LDL-C exist among equations, particularly at TG levels of ≥150 mg/dL and/or lower LDL-C levels. Reliance on the Friedewald and Sampson equations may result in the underestimation and undertreatment of LDL-C in those at increased risk.