Inconsistent Classification of "Outpatient" Surgeries Leads to Different Outcomes Following Total Hip Arthroplasty in Medicare Beneficiaries: A Critical Analysis.

BACKGROUND: With rising utilization of outpatient total hip arthroplasty (THA) in older patients including Medicare beneficiaries, the objective was to compare differences in definition including (1) patient demographics; (2) lengths of stay (LOS); and (3) outcomes of "outpatient" (stated status) versus "same-day discharge" (SDD) (actual LOS = 0 days) utilizing a nationwide database. METHODS: A national database from 2015 to 2019 was queried for Medicare-aged patients undergoing outpatient THA. Total outpatient THAs (N = 6,072) were defined in one of 2 ways: either "outpatient" by the hospital (N = 2,003) or LOS = 0 days (N = 4,069). Demographics, LOS, discharge destinations, and complications were compared between groups. Logistic regression models computed odds ratios (ORs) for factors leading to complications, readmissions, and nonhome discharges. P values < .008 were significant. RESULTS: Women (OR: 1.19, P = .002), diabetes mellitus (OR: 1.31, P = .003), general anesthesia (OR: 1.24, P = .001), and longer operative times (≥95 minutes) (OR: 1.82, P < .001) were associated with 'outpatient' designation versus SDD. Within the hospital-defined 'outpatient' cohort, 49.1% (983 of 2,003) were discharged the same day (LOS = 0 days), and 21.8% had LOS 2 or more days. The hospital-defined 'outpatient' cohort had greater odds of nonhome discharges (6.3 versus 2.8%; OR: 1.88, P < .001) compared to SDD surgeries. The incidence was higher for any complication among hospital-defined 'outpatient' designated patients compared to SDD (5.5 versus 3.9%, P = .007). CONCLUSIONS: Outpatient surgeries may be misleading and often do not correlate with SDD, as over 20% remain in the hospital 2 or more days. Investigators should quantitatively define the "outpatient" status by actual LOS to allow standardization and results comparison. LEVEL OF EVIDENCE: III.

Fast-track protocols for patients undergoing spine surgery: a systematic review.

BACKGROUND CONTEXT: Fast-track is an evidence-based multidisciplinary strategy for pre-, intra-, and postoperative management of patients during major surgery. To date, fast-track has not been recognized or accepted in all surgical areas, particularly in orthopedic spine surgery where it still represents a relatively new paradigm. PURPOSE: The aim of this review was provided an evidenced-based assessment of specific interventions, measurement, and associated outcomes linked to enhanced recovery pathways in spine surgery field. METHODS: We conducted a systematic review in three databases from February 2012 to August 2022 to assess the pre-, intra-, and postoperative key elements and the clinical evidence of fast-track protocols as well as specific interventions and associated outcomes, in patients undergoing to spine surgery. RESULTS: We included 57 full-text articles of which most were retrospective. Most common fast-track elements included patient's education, multimodal analgesia, thrombo- and antibiotic prophylaxis, tranexamic acid use, urinary catheter and drainage removal within 24 hours after surgery, and early mobilization and nutrition. All studies demonstrated that these interventions were able to reduce patients' length of stay (LOS) and opioid use. Comparative studies between fast-track and non-fast-track protocols also showed improved pain scores without increasing complication or readmission rates, thus improving patient's satisfaction and functional recovery. CONCLUSIONS: According to the review results, fast-track seems to be a successful tool to reduce LOS, accelerate return of function, minimize postoperative pain, and save costs in spine surgery. However, current studies are mainly on degenerative spine diseases and largely restricted to retrospective studies with non-randomized data, thus multicenter randomized trials comparing fast-track outcomes and implementation are mandatory to confirm its benefit in spine surgery.

Benign prostatic hyperplasia is associated with increased 90-day medical complications but not peri-prosthetic joint infections following reverse shoulder arthroplasty.

INTRODUCTION: Studies have shown male sex to be a predisposing factor for peri-prosthetic joint infections (PJIs). Symptomatic benign prostatic hyperplasia (BPH) has been suggested as an additional risk for PJI. This study aimed to assess the impact of BPH on (1) lengths of stay (LOS), (2) complications (medical and implant-related), (3) readmission rates, and (4) healthcare expenditures after reverse shoulder arthroplasty (RSA). METHODS: Utilizing a nationwide sample from the 2010-2020 PearlDiver insurance database, an analysis was performed retrospectively for all males who underwent primary RSA. Males with BPH (n = 2,184) represented the study group and were ratio-matched with men without a history of BPH (n = 10,832) in a 1:5 manner by medical comorbidities. T-tests compared LOS and healthcare expenditures. Multivariate logistic regression models were used to determine the effect of BPH on 90-day medical complications, 2-year implant complications, and readmissions. A p value less than 0.001 was statistically significant. RESULTS: In-hospital LOS (1.96 days vs. 1.99 days, p = 0.683) did not significantly differ between cohorts. Males with BPH had significantly greater occurrence and odds (34.3% vs. 21.2%, odds ratio (OR):1.84, p < 0.0001) of all 90-day medical complications, including urinary tract infections (9.3% vs. 3.1%, OR:3.23, p < 0.0001), pneumonias (6.0% vs. 3.9%, OR:1.61, p < 0.0001), and acute kidney injuries (7.7% vs. 5.0%, OR:1.60, p < 0.0001). Two-year implant-related complications were comparable between study and control groups (12.2% vs 10.9%, OR:1.14, p = 0.073), including PJIs (2.3% vs. 2.2%, OR:1.02, p = 0.874). Readmission rates (1.88% vs. 2.11%, p = 0.482) and average global 90-day reimbursements ($26,301 vs. $24,399), p = 0.535) were similar between men with and without BPH. DISCUSSION: Males with a history of BPH have greater rates of medical complications, including UTIs and acute kidney injuries, within 90 days following RSA. BPH does not appear to be a risk factor for 2-year implant-related complications including PJIs. LEVEL OF EVIDENCE: III.

Serum Lactate as an Independent Predictor of In-Hospital Mortality in Intensive Care Patients.

PURPOSE: The aim of this study was to check if serum lactate was independently associated with mortality among critically ill patients. MATERIALS AND METHODS: This was a single-center, retrospective cohort study. All adult patients (>18 years of age) who had at least 1 measurement of lactate within 24 hours of admission to intensive care unit (ICU) between January 2002 and December 2017 were included in the analysis. Patients were stratified into 3 groups: those with a serum lactate of <2 mmol/L (normal level), 2 to 4 mmol/L (intermediate level), and >4 mmol/L (high level). The primary outcome was in-hospital mortality. Secondary outcomes included ICU and hospital lengths of stay and mechanical ventilation duration. To determine the association between lactate level and hospital mortality, bivariate and multivariate logistic regression analyses were performed. RESULTS: Of the 16,447 patients admitted to the ICU, 8167 (49.65%) had normal levels, 4648 (28.26%) had an intermediate, and 3632 (22.09%) had high lactate levels. Hospital mortality was the highest in high lactate level, followed by the intermediate and the normal level group (47.4% vs 26.5% vs 19.6%; P < .0001). Intermediate and high lactate levels were independent predictors of hospital mortality (odds ratio [OR], 1.32; 95% confidence interval [CI]: 1.20-1.46, and 1.94; 95% CI, 1.75-2.16, respectively) as well as ICU mortality (OR, 1.47; 95% CI, 1.30-1.66 and 2.56; 95% CI, 2.27-2.88, respectively). CONCLUSIONS: Intensive care unit serum lactate is associated with increased ICU and hospital mortality, independent of comorbidities, organ dysfunction, or hemodynamic status.

Parkinson's disease increases the risk of perioperative complications after total knee arthroplasty: a nationwide database study.

PURPOSE: Therefore, the purpose of this study was to evaluate the short-term perioperative outcomes of PD patients who underwent total knee arthroplasty (TKA). We specifically evaluated: (1) perioperative surgical and medical complications; (2) lengths of stay (LOS); and (3) total hospital charges. METHODS: The Nationwide Inpatient Sample was used to identify PD patients who underwent TKA between 2002 and 2013. To control for potential confounders, PD TKA and non-PD TKA patients were propensity score matched (1:3) based on age, sex, ethnicity, Charlson Comorbidity Index, and insurance type. A total of 31,979 PD and 95,596 non-PD TKA patients were included. RESULTS: PD patients had a 44% higher risk of suffering from any complication (OR 1.44; 95% CI 1.35-1.54), a 45% increased risk for any medical complication (OR 1.45; 95% CI 1.36-1.55), and a 9% higher risk for any surgical complication (OR 1.09; 95% CI 0.84-1.41). Compared to the matched cohort, PD patients had a mean LOS that was 6.5% longer (95% CI 5.46-7.54) and mean total hospital charges that were 3.05% higher (95% CI 1.99-4.11). CONCLUSIONS: PD patients are more likely to have postoperative complications, longer LOS, and higher costs after TKA than non-PD TKA patients. Since many of these complications can be prevented, a team-based multi-specialty patient optimization is needed. LEVEL OF EVIDENCE: Level III, therapeutic study.

Operative Times Can Predict and Are Correlated With Lengths-of-Stay in Primary Total Knee Arthroplasty: A Nationwide Database Study.

BACKGROUND: The specific influence of operative times on lengths-of-stay (LOS) has not been well assessed and is therefore an important topic of evaluation for multiple reasons, including potential economic implication. The purpose of this study is to (1) identify predictors of longer operative times; (2) identify predictors of longer LOS; and (3) evaluate the effects of operative times on LOS in primary total knee arthroplasty (TKA). METHODS: The National Surgical Quality Improvement Program database was queried for primary TKAs performed between 2008 and 2016, yielding 225,344 cases. Multivariate analysis was performed to determine the effect of operative times on LOS after adjusting for patient factors. Univariate analyses were performed with 1-way analysis of variance (ANOVA), linear regression, and independent sample t-tests where appropriate. Multivariate analysis was performed with a multiple linear regression model adjusted for patient age, sex, and body mass index (BMI). RESULTS: The mean operative time was 93 ± 35 minutes and the mean LOS was 3 ± 3 days. Young age, male sex, and obesity were predictors of longer operative times (P < .001). Similarly, there were significant associations of age, sex, and BMI with LOS (P < .001). Increasing 30-minute operative time intervals were associated with increasing LOS (P < .001). Longer operative times had significant associations with longer LOS even after adjusting for patient factors (ß = 0.076, SE < 0.001, P value < .001). Out of all study covariates, operative times had the greatest effect on LOS. CONCLUSION: This study provides unique insight by directly correlating operative times to LOS in over 200,000 TKAs. The results from this study indicate that there is a strong correlation between operative times and LOS, so that operative time had a greater association than age, sex, and BMI with postoperative TKA LOS.

Perioperative Outcomes and Complications in Patients With Heart Failure Following Total Knee Arthroplasty.

BACKGROUND: Heart failure (HF) is a common comorbidity in the aging population and they will require major elective surgery. The purpose of this study is to determine if HF is a risk factor for adverse perioperative outcomes and short-term complications following total knee arthroplasty. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify all patients who underwent total knee arthroplasty for osteoarthritis from 2008 to 2014. Any diagnosis other than osteoarthritis was excluded. A total of 111,634 patients were identified and 251 of these patients had a preoperative diagnosis of HF. The main outcomes included operative time, lengths-of-stay, discharge disposition, return to operating room, readmission, and short-term complications, including death. RESULTS: Patients with HF were found to have longer hospital stays (ß = 0.59, 95% confidence interval [CI] 0.12-1.06) following total knee arthroplasty, and were more likely to return to the operating room (odds ratio 2.00, 95% CI 1.01-3.94) and be readmitted (OR 1.88, 95% CI 1.21-2.94). In addition, HF was found to be a risk factor for 1 or more complications (OR 1.41, 95% CI 1.05-1.90), wound dehiscence (OR 4.86, 95% CI 1.68-14.03), and myocardial infarction (OR 4.81, 95% CI 1.90-12.16) postoperatively. CONCLUSION: Patients with HF are more likely to have a longer length-of-stay, return to the operating room, and be readmitted. Additionally, they have a higher risk for at least one postoperative complication, myocardial infarction, and wound dehiscence.

Chronic Obstructive Pulmonary Disease Is Associated With Short-Term Complications Following Total Hip Arthroplasty.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Furthermore, COPD patients are at increased risk of complications following surgery. The purpose of this study was to evaluate the postoperative total hip arthroplasty (THA) outcomes of COPD patients. Specifically, we asked the following questions: (1) Is COPD associated with adverse perioperative outcomes and (2) Does COPD increase the risk of short-term complications following THA? METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 64,796 patients who underwent THA between 2008 and 2014. A total of 2426 patients with COPD were identified. COPD and non-COPD cohorts were compared based on the following outcomes: hospital length-of-stay, operative times, discharge disposition, and 30-day postoperative complications. RESULTS: COPD patients were found to have a longer length-of-stay and be discharged to an extended care facility (P < .001). COPD patients were also at significantly (P < .05) increased risk for any complication, such as mortality, myocardial infarction, pneumonia, septic shock, unplanned reintubation, use of a mechanical ventilator >48 hours, deep infection, require a blood transfusion, return to operating room, and a readmission within 30 days postoperatively. CONCLUSIONS: COPD patients are more likely to suffer from postoperative complications following THA when compared to non-COPD patients. Many of these complications are medical, pulmonary evaluation and medical optimization are a critical step in preoperative management for these patients.

Does Parkinson Disease Increase the Risk of Perioperative Complications After Total Hip Arthroplasty? A Nationwide Database Study.

BACKGROUND: Parkinson disease (PD) is the second most common neurodegenerative disorder in the United States, affecting over 1 million people. As part of the disease process, PD can cause poor bone quality and other musculoskeletal problems that can affect a patient's quality of life. With advances in treatment, PD patients can be more active and may be candidates for total hip arthroplasty (THA). However, there is a paucity of literature on the outcomes of THA in PD patients. Therefore, the purpose of this study was to evaluate the perioperative outcomes of PD patients who underwent THA. Specifically, we assessed: (1) perioperative surgical and medical complications; (2) lengths of stay (LOSs); and (3) total hospital charges. METHODS: Using the Nationwide Inpatient Sample, patients who had PD and underwent THA between 2002 and 2013 were identified. With the use of propensity scores, PD patients were matched in a 1:3 ratio to patients without PD by the year of surgery, age, gender, race, Charlson/Deyo score, and insurance type. This yielded a total of 10,519 PD and 31,679 non-PD THA patients. Regression analyses were used to compare the risk of perioperative complications (any, surgical, medical), the percent differences in mean LOS, and the percent differences in total hospital charges. RESULTS: Compared with the matched cohort, PD patients had a 52% higher risk for any complication (odds ratio [OR] = 1.52; 95% confidence interval [CI], 1.37-1.69), a 30% higher risk for any surgical complication (OR = 1.30; 95% CI: 0.88-1.91), and a 54% higher risk for any medical complication (OR = 1.54; 95% CI, 1.38-1.71). Specifically, PD patients were more likely to have postoperative delirium (OR = 2.61; 95% CI: 1.77-3.85), altered mental status (OR = 3.01; 95% CI: 1.35-6.71), urinary tract infection (OR = 1.34; 95% CI: 1.09-1.76), and blood transfusion (OR = 1.62; 95% CI: 1.44-1.82). Also, PD patients had a mean LOS that was 8.57% longer (P < .0001), and mean total hospital charges that were 3.85% higher (P < .0001). CONCLUSION: Orthopedic surgeons and neurologists should be involved in the preoperative counseling of PD patients regarding their potential increased risks associated with THA, which could help optimize their preoperative care. Furthermore, the risk of complications and higher costs could potentially lead to the development of different reimbursement methods in this population of patients.

Chronic Obstructive Pulmonary Disease Is Associated With Short-Term Complications Following Total Knee Arthroplasty.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major global health issue and a leading cause of morbidity and mortality. Patients with COPD are at increased risk of complications following surgery. The purpose of this study is to evaluate the postoperative total knee arthroplasty (TKA) outcomes in these patients in comparison to a non-COPD matching cohort. Specifically, we asked the following questions: (1) "Is COPD associated with adverse perioperative outcomes?" and (2) "Does COPD increase the risk of short-term complications following TKA?" METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 111,168 patients who underwent TKA between 2008 and 2014. A total of 3975 patients with COPD were identified. Both COPD and non-COPD cohorts were compared in terms of the following outcomes: hospital length of stay, discharge disposition, and 30-day postoperative complications. RESULTS: COPD was a predictor for a prolonged length of stay and a discharge to an extended care facility (P < .001). They were at significantly increased risk of any complication including increased mortality, pneumonia, reintubation, use of a mechanical ventilator for >48 hours, cardiac arrest, progressive renal insufficiency, deep infection, return to operating room, and a readmission within 30 days postoperatively. CONCLUSION: Patients with COPD are more likely to experience postoperative complications following TKA when compared to non-COPD patients. Pulmonary evaluation and optimization are crucial to minimize adverse events from occurring in this difficult-to-treat population.

Opioid Use Disorder in Patients Undergoing Primary 1- to 2-Level Anterior Cervical Discectomy and Fusion Is Associated With Longer In-Hospital Lengths of Stay and Higher Rates of Readmissions, Complications, and Costs of Care.

STUDY DESIGN: Retrospective study. OBJECTIVE: To determine whether opioid use disorder (OUD) patients undergoing 1- to 2-level anterior cervical discectomy and fusion (1-2ACDF) have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) complications; and 4) costs. METHODS: OUD patients undergoing primary 1-2ACDF were identified within the Medicare database and matched to a control cohort in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 80,683 patients who underwent 1-2 ACDF with (n = 13,448) and without (n = 67,235) OUD. Outcomes analyzed included in-hospital LOS, 90-day readmission rates, 90-day medical complications, and costs. Multivariate logistic regression analyses were used to calculate odds-ratios (OR) for medical complications and readmissions. Welch's t-test was used to test for significance for LOS and cost between the cohorts. An alpha value less than 0.002 was considered statistically significant. RESULTS: OUD patients were found to have significantly longer in-hospital LOS compared to their counterparts (3.41 vs. 2.23-days, P < .0001), in addition to higher frequency and odds of requiring readmissions (21.62 vs. 11.57%; OR: 1.38, P < .0001). Study group patients were found to have higher frequency and odds of developing medical complications (0.88 vs. 0.19%, OR: 2.80, P < .0001) and incurred higher episode of care costs ($20,399.62 vs. $16,812.14, P < .0001). CONCLUSION: The study can help to push orthopaedic surgeons in better managing OUD patients pre-operatively in terms of safe discontinuation and education of opioid drugs and their effects on complications, leading to more satisfactory outcomes.

Sepsis in end-stage renal disease patients: are they at an increased risk of mortality?

OBJECTIVES: This study aims to examine the outcome of end-stage renal disease (ESRD) patients admitted with sepsis to the intensive care unit (ICU). DESIGN: Single centre, retrospective cohort study. SETTING: The study was conducted in the Intensive Care Department of King Abdulaziz Medical City, Riyadh, Saudi Arabia. PARTICIPANTS: Data were extracted from a prospectively collected ICU database from 2002 to 2017. Patients were considered to have sepsis based on the sepsis-3 definition and were stratified into 2 groups based on the presence or absence of ESRD. PRIMARY AND SECONDARY OUTCOMES: The primary outcome of the study was in-hospital mortality. Secondary outcomes included ICU mortality, ICU and hospital lengths of stay, and mechanical ventilation duration. RESULTS: A total of 8803 patients were admitted to the ICU with sepsis during the study period. 730 (8.3%) patients had ESRD. 49.04% of ESRD patients with sepsis died within their hospital stay vs. 31.78% of non-ESRD patients. ESRD septic patients had 1.44 greater odds of dying within their hospital stay as compared to septic non-ESRD patients (OR 1.44, 95% CI 1.03-1.53). Finally, the predictors of hospital mortality in septic ESRD patients were found to be mechanical ventilation (OR 3.36; 95% CI 2.27-5.00), a history of chronic liver disease (OR 2.26; 95% CI 1.26-4.07), and use of vasopressors (OR 1.74; 95% CI 1.19-2.54). Among patients with ESRD, hospital mortality was higher in subgroups of patients with chronic cardiac (OR 1.86 (1.36-2.53) vs. 1.19 (0.96-1.47)) and chronic respiratory illnesses (OR 2.20 (1.52-3.20) vs. 1.21 (0.99-1.48)). CONCLUSION: ESRD patients admitted to the intensive care unit with sepsis are at greater odds of mortality compared to patients with non-ESRD. This risk is particularly increased if these patients have a concomitant history of chronic cardiac and respiratory illnesses.Key MessagesSepsis and bacterial infections are very common in ESRD patients and following cardiovascular disease; sepsis is the second leading cause of death in patients with ESRD.This study aims to examine the outcome of patients with end-stage renal disease (ESRD) patients admitted with sepsis to the intensive care unit (ICU).The results of this study have shown that end-stage renal disease is associated with greater odds of ICU and hospital mortality among septic patients admitted to an intensive care unit.ESRD patients were also more likely to be started on vasopressors and mechanical ventilation.

Introduction of day case hip and knee replacement programme at an inpatient ward is safe and may expedite shortening of hospital stays of traditional arthroplasties.

PURPOSE: We investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward. METHODS: 200 patients underwent elective, unilateral primary day case total hip (THA, n = 94), total knee (TKA, n = 60) and unicondylar knee replacements (UKA, n = 46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n = 6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period. RESULTS: 166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5%), urine retention (3%) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%. CONCLUSION: Introduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.

Hospitalization Outcomes of Delirium in Patients Admitted to Acute Care Hospitals in Their Last Year of Life: A Population-Based Retrospective Cohort Study.

CONTEXT: Delirium is a highly distressing neurocognitive disorder for patients at the end of life. OBJECTIVES: To compare hospitalization outcomes between patients with and without delirium admitted to acute care hospitals in the last year of life. METHODS: Using linked administrative data from ICES (previously known as the Institute for Clinical Evaluative Sciences), this population-based retrospective cohort study included adults who died in Ontario between January 1, 2014 and December 31, 2016 and were admitted to an acute care hospital in their last year of life. Delirium was identified via diagnosis codes on the hospitalization discharge record. Outcomes included lengths of stay, discharge location, and in-hospital mortality. We used multivariable generalized estimating equations to compare outcomes between patients with and without delirium. RESULTS: Of 208,715 decedents, 9.3% experienced delirium in at least one hospitalization in the last year of life. The mean hospitalization lengths of stay was 13.8 days in patients with delirium (SD = 21.1) or 1.80 times longer (95% CI = 1.75-1.84) compared with those without delirium. Among patients discharged alive, patients with delirium were 1.32 times (95% CI = 1.27-1.38) more likely to be discharged to another institution rather than discharged home. There was no difference in in-hospital mortality between patients with and without delirium (relative risk = 1.01; 95% CI = 0.98-1.05). CONCLUSION: In the last year of life, hospitalized patients with recorded delirium experience poorer outcomes, including longer lengths of stay and increased risk of postdischarge institution use, compared with those without delirium. These outcomes illustrate added burden for patients, their families, and the health care system, thus highlighting the need for delirium prevention and early detection in addition to informed transitional care decisions.

A matched-control analysis on the effects of alcohol use disorder following primary reverse shoulder arthroplasty.

INTRODUCTION: The purpose of this study was to determine whether alcohol use disorder (AUD) patients undergoing reverse shoulder arthroplasty (RSA) have increased: 1) lengths of stay (LOS); 2) complications; and 3) costs. METHODS: The study identified 19,168 patients in the study (n = 3198) and control (n = 15,970) cohort. In-hospital LOS, 90-day complications, and costs were assessed. RESULTS: AUD patients had significantly longer LOS (3- vs. 2-days, p < 0.0001), higher9 0-day medical complications (49.59 vs. 14.81%; p < 0.0001), and 90-day costs of care ($18,763.25 vs. $16,035.49, p < 0.0001). CONCLUSIONS: The study is useful as it can allow healthcare professionals to adequately counsel these patients.

The effect of operative time on in-hospital length of stay in revision total knee arthroplasty.

BACKGROUND: Revision total knee arthroplasty (TKA) is associated with increased rates of infections, readmissions, longer operative times, and lengths-of-stay (LOS) compared to primary TKA. Additionally, increasing operative times and prolonged postoperative LOS are independent risk factors for these postoperative complications in lower extremity total joint arthroplasty (TJA). This has led to an increased effort to reduce these risk factors in order to improve patient outcomes and reduce cost. However, the relationship between operative time and LOS has not been well assessed in revision arthroplasty. Therefore, the purpose of this study was to: (I) identify predictors of longer operative times; (II) identify predictors of longer LOS; and (III) evaluate the effects of operative time, treated as both a categorical variable and a continuous variable, on LOS after revision TKA. METHODS: The NSQIP database was queried for all revision TKA cases (CPT code 27487) between 2008 and 2016 which yielded 10,604 cases. Mean operative times were compared between patient demographics including age groups, sex, and body mass indexes (BMIs). To determine predictors of LOS, mean LOS were also compared between patient demographics in the same groups. To assess the correlation of operative time on LOS, the mean LOS for 30-minute operative time intervals were compared. Univariate analysis was performed with one-way analysis of variance (ANOVA) and t-tests. A multivariate analysis with a multiple linear regression model was performed to evaluate the association of LOS with operative times after adjusting for patient age, sex, and BMI. RESULTS: The mean LOS for revision TKA was 4 (±3) days. Further analysis showed that young age is associated with increased LOS (P<0.01). An analysis of operative times showed positive correlations with young age, BMI greater than 30 and male sex (P<0.05). The mean LOS of revision TKA patients was found to increase with increasing operative time in 30-minute intervals (P<0.001). Multivariate analysis showed that longer operative times had significant associations with longer LOS even after adjusting for patient factors (ß=0.102, SE =0.001, P<0.001). These results also showed that out of all of the study covariates, operative times had the greatest effect on LOS after revision TKA. CONCLUSIONS: Revision TKA is a complex procedure, often requiring increased operative times compared to primary TKA. This study provides unique insight by correlating operative times to LOS in over 10,000 revision TKAs from a nationwide database. Our results demonstrate that out of all the study covariates (age, sex, and BMI), operative times had the greatest effect on LOS. The results from this study indicate that less time spent in the operating room can lead to shorter LOS for revision TKA patients. This relationship further underscores the need for improved preoperative planning and intra-operative efficiency in an effort to decrease LOS and improve patient outcomes.

Pneumococcal polysaccharide vaccine associated with reduced lengths of stay for cardiovascular events hospital admissions: Experience from the Hunter Community Study.

BACKGROUND: The pneumococcal polysaccharide vaccine (PPV) has been associated with reduced risk of cardiovascular events in human observational studies. Animal studies suggest that the phosphorylcholine epitope in the Streptococcus pneumoniae cell wall is structurally similar to oxidized low-density lipoprotein (oxLDL), hence PPV induces the production of antibodies that cross-react with anti-oxLDL and may cause regression of atherosclerotic plaque. We set out to determine the strength of association between PPV administration and reduction in cardiovascular events. METHODS: A longitudinal, population-based cohort study of older Australians, from the Hunter Community Study, with up to 11 years of follow-up. We included participants aged ≥ 65 years at baseline (2004-2008), without a history of cardiovascular disease (CVD). History of PPV administration at baseline was the main exposure of interest. "Total number of hospital bed-days with CVD primary diagnosis" was one of the main outcomes measured. Models were adjusted for age, diabetes, alcohol intake, and smoking status. Influenza vaccine was the control exposure used and fracture bed-days was the control outcome used, to investigate the potential for residual confounding. RESULTS: 91 of the total 1074 participants (mean age = 72, male = 45%) experienced a CVD event during follow-up. PPV (regardless of influenza vaccine) was associated with a significant reduction in CVD bed-day, (n = 863, incident rate ratio, IRR = 0.65, 95%CI: 0.45-0.94, p = 0.02), but influenza vaccine (regardless of PPV) was not (n = 864, IRR = 0.86, 95%CI: 0.54-1.35, p = 0.51). Furthermore, PPV adjusted for influenza vaccine remained associated with CVD bed-days (IRR = 0.64, 95%CI: 0.43-0.96, p = 0.03) but was not associated with fracture bed-days (IRR = 0.75, 95%CI: 0.28-2.00, p = 0.56). CONCLUSION: PPV demonstrated a 35% reduction in CVD bed-days. This finding was robust to residual confounding, using a control exposure and a control outcome, eliminating the concern for healthy-user bias. A large double-blinded placebo-controlled RCT is underway to confirm our finding and to explore the proposed mechanism of action (ACTRN12615000536561).

Total shoulder arthroplasty in octogenarians: Is there a higher risk of adverse outcomes?

This study used the National Surgical Quality Improvement Program to evaluate octogenarians who underwent total shoulder arthroplasty (TSA). Specifically, we evaluated: (1) patient demographics; (2) perioperative factors; and (3) 30-day postoperative complications. Compared to controls, the octogenarians had more females, white patients, lower BMIs, fewer smokers, less functionally independent, higher ASA scores, shorter operative times, and longer LOS. Octogenarians had greater odds for developing any (OR = 2.05; 95%CI, 1.70-2.46), any major (OR = 2.28; 95%CI, 1.66-3.13), and any minor (OR = 1.99; 95%CI, 1.63-2.45) complications. Perioperative risk management strategies for elective TSA in the elderly may help mitigate the increased perioperative risks associated with age.

US emergency nurses' perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: A mixed-methods study.

BACKGROUND: Behavioural health patients often have longer lengths of stay in the emergency department compared with general medical patients, and their modalities of care are not well documented. This study's purpose is to describe US emergency nurses' estimates of lengths of stay for behavioural health patients, explore factors affecting length of stay, and assess nurses' perceptions of their skills, beliefs/attitudes, and confidence in caring for this population. METHODS: Using a mixed-methods design with demographically-diverse samples of emergency nurses, survey data (N=1229) were analysed using descriptive statistics, correlation coefficients, and linear regression. Focus group participant data (N=20) were analysed for themes using constant comparison. RESULTS: Findings suggest that shorter lengths of stay are associated with higher levels of perceived nursing confidence/preparation to care for this population, along with the availability of appropriate resources and protocols/standards of care (p=0.01). Longer lengths of stay are associated with an absence of dedicated inpatient space for managing the care of these patients. CONCLUSIONS: Participants note a lack of education, resources, and treatment options tailored to the delivery of safe, effective care for behavioural health patients. The use of trained specialists and additional guidelines/protocols may help move patients through the emergency department faster and with greater surety.

Incidence trends and predictors for cost and average lengths of stay in colorectal cancer surgery.

AIM: To evaluate the changing trends and outcomes of colorectal cancer (CRC) surgery performed at a large single institution in Taiwan. METHODS: This study retrospectively analyzed 778 patients who received colorectal cancer surgery at E-Da Hospital in Taiwan from 2004 to 2009. These patients were from health examination, inpatient or emergency settings. The following attributes were analyzed in patients who had undergone CRC surgical procedures: gender, age, source, surgical type, tumor number, tumor size, number of lymph node metastasis, pathologic differentiation, chemotherapy, distant metastases, tumor site, tumor stage, average hospitalization cost and average lengths of stay (ALOS). The odds ratio and 95% confidence intervals were calculated to assess the relative rate of change. Regression models were employed to predict average hospitalization cost and ALOS. RESULTS: The study sample included 458 (58.87%) males and 320 (41.13%) females with a mean age of 64.53 years (standard deviation, 12.33 years; range, 28-86 years). The principal patient source came from inpatient and emergency room (96.02%). The principal tumor sites were noted at the sigmoid colon (35.73%) and rectum (30.46%). Most patients exhibited a tumor stage of 2 (37.28%) or 3 (34.19%). The number of new CRC surgeries performed per 100000 persons was 12.21 in 2004 and gradually increased to 17.89 in 2009, representing a change of 46.52%. During the same period, the average hospitalization cost and ALOS decreased from $5303 to $4062 and from 19.7 to 14.4 d, respectively. The following factors were associated with considerably decreased hospital resource utilization: age, source, surgical type, tumor size, tumor site, and tumor stage. CONCLUSION: These results can be generalized to patient populations elsewhere in Taiwan and to other countries with similar patient profiles.