Dataset Information

Risk stratification in primary total joint arthroplasty: the current state of knowledge.

ABSTRACT:

Background

As we transition to value-based care delivery models, risk stratification in total joint arthroplasty is more important than ever. The purpose of this study was to identify patients who would likely require higher level of care and may not be suitable for inclusion in bundled payment models.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent primary total joint arthroplasty between 2011 and 2012. Five types of adverse events were assessed: medical complications, surgical complications, readmission, reoperation, and mortality. Univariate and multivariate logistic regression analyses were performed using a large number of demographic and morbidity variables.

Results

A total of 14,185 patients were identified. The 30-day medical complication, surgical complication, readmission, reoperation, and mortality rates were 2.0%, 3.2%, 4.0%, 1.5%, and 0.2%, respectively. Among the different variables assessed, only the American Society of Anesthesiologists (ASA) physical classification system was a significant risk factor for most outcomes assessed. Peripheral vascular disease was the most significant risk factor for medical complications and reoperation (odds ratio, 2.73 and 3.23, respectively). Bleeding disorders were the most significant risk factor for readmission and mortality (odds ratio, 2.03 and 5.86, respectively).

Conclusions

ASA score is a more reliable risk stratification tool than Charlson Comorbidity Index, but it is not sufficient by itself. Patients with higher ASA scores combined with peripheral vascular disease and/or bleeding disorders are at especially high risk of developing postsurgical adverse events and may not be suitable for inclusion in bundled payment models. These data can be used to develop better risk stratification models that are critically needed.

SUBMITTER: Gronbeck C

PROVIDER: S-EPMC6470321 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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Publications

Risk stratification in primary total joint arthroplasty: the current state of knowledge.

Gronbeck Christian C Cote Mark P MP Lieberman Jay R JR Halawi Mohamad J MJ

Arthroplasty today 20190205 1

<h4>Background</h4>As we transition to value-based care delivery models, risk stratification in total joint arthroplasty is more important than ever. The purpose of this study was to identify patients who would likely require higher level of care and may not be suitable for inclusion in bundled payment models.<h4>Methods</h4>The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent primary total joint arthroplasty between 2 ...[more]

PMID: 31020036

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Project description:BackgroundPrior studies have suggested that preoperative dehydration increases odds of perioperative complications in several areas of orthopedic surgery. This study aimed to evaluate whether preoperative hydration status is associated with the incidence of short-term complications after primary total joint arthroplasty.MethodsThe 2012-2019 National Surgical Quality Improvement Program (NSQIP) database was used to explore the relationship between preoperative dehydration (ratio of preoperative BUN divided by preoperative Creatinine (BUN/Creatinine) > 20) and perioperative outcomes of total hip (THA) and total knee arthroplasty (TKA) patients. Univariate comparisons and multivariate regression analyses were conducted to identify specific complications that occurred more often in patients with preoperative dehydration.ResultsOf 188,629 THA and 332,485 TKA patients, 46.3 and 47.0% had preoperative dehydration, respectively. After controlling for demographics and comorbidities, dehydrated THA patients were no more likely to experience a complication compared to their non-dehydrated counterparts (relative risk [RR] = 0.97, 99.7% Confidence Interval [CI]: 0.92-1.03, P = 0.138) nor increased risk of blood transfusion (RR = 1.02, CI = 0.96-1.08, P = 0.408). Similar to THA patients, dehydrated TKA patients were not more likely to have a complication after surgery (RR = 0.97, CI = 0.92-1.03, P = 0.138) and were at no greater risk of transfusion (RR = 1.02, CI = 0.96-1.07, P = 0.408). A sub-analysis covering only patients with BUN and Cr values determined within 24 h after surgery was performed and similarly found no significant increase in perioperative complications or transfusion.ConclusionOverall, preoperative dehydration in patients undergoing THA/TKA did not appear to increase risk of transfusion or other perioperative complications. Further research is needed to characterize the role of hydration prior to elective total joint arthroplasty.

Project description:BackgroundTrapeziometacarpal (TMC) osteoarthritis can be painful and cause disability for patients. Total joint replacement of the TMC joint provides a pseudo arthrosis with good restoration of the thumb motion and pain relief in most patients. But there is also a risk of no improvement following the operation. The purpose of this study was to identify patients at risk of no clinically important improvement following operative treatment of osteoarthritis of the TMC joint.MethodsWe included 287 consecutive patients (225 women, 62 men) treated with total joint replacement of the TMC joint due to osteoarthritis with a mean age of 58.9 years (range 41-80) in a prospective cohort study. We collected information preoperatively and 12 months postoperatively on disabilities of the arm, shoulder and hand score (DASH), grip strength and pain at rest and activity on a visual analogue scale (VAS).ResultsWe found a statistically significant improvement in DASH from 42.0 to 15.9 (p < 0.001), VAS at rest from 3.5 to 0.6 (p < 0.001), VAS at activity from 7.9 to 2.5 (p < 0.001) and grip strength from 21.6 kg to 27.6 kg (p < 0.001) 12 months after the operation, when analysed as a group. There was an increased risk of no clinically important improvement in hand function for patients with preoperative high preoperative grip strength. Also, we found an increased risk of no clinically important improvement in female patients when using VAS as outcome.ConclusionHowever, we were unable to detect one isolated preoperative predictor as indicator of successful result after operative treatment of TMC osteoarthritis, and as so it was not possible to establish a clinical valid tool for patient selection before surgery. Informed consent was obtained from all patients for being included in the study. The study needed no approval from The Regional Committee of Biomedical Research Ethics as the data was collected, as part of our normal pre- and postoperative clinical pathway, but the study is part of an outcome study of the results after total joint arthroplasty (TJA) of the TMC joint registered in Clinicaltrials.gov (NCT01554748).Trial registrationClinicaltrials.gov (NCT01554748). Registered 15 March 2012.

Project description:BackgroundTotal joint arthroplasty (TJA), although considered to be highly beneficial, is associated with substantial costs to the US healthcare system. Cost utility analysis has become an increasingly important means to objectively evaluate the value of a healthcare intervention from the perspective of both extending the quantity and improving the quality of life. Relatively little is known about the overall cost utility analysis evidence base in TJA.Questions/purposesThe goals of this review were to (1) determine the cost utility of TJA interventions; (2) critically assess the quality of published US-based cost utility analyses using the Quality of Health Economic Studies instrument; and (3) determine what characteristics were common among studies receiving a high quality score.MethodsA systematic review of the literature using the MEDLINE database was performed to compile findings and critically appraise US-based cost utility analysis studies for total hip and knee arthroplasty. Based on review of 676 identified articles, 23 studies were included. We used the Quality of Health Economic Studies instrument to assess study quality and one-sided Fisher's exact tests were applied to analyze the predictors of high-quality cost utility analysis.ResultsVery few studies compare the cost utility of TJA versus nonoperative intervention; however, the available evidence suggests that TJA can be cost-saving and is highly cost-effective compared with conservative management of end-stage arthritis. The majority of identified studies are focused on the cost utility of new implant technologies or comparisons among surgical alternatives. These studies suggest that the upfront costs associated with new technologies are cost-effective when there is a major reduction in a future cost. The quality of identified studies is quite high (Quality of Health Economic Studies Instrument score: mean 86.5; range, 63-100). National funding source (p = 0.095) and lifetime horizon for analysis (p = 0.07) correlate with high-quality evidence but do not reach significance.ConclusionsOver the past 15 years, there has been a major increase in the volume of cost utility analyses published in total hip and knee arthroplasty. The quality of cost utility analyses published during that period is good. As increasing attention is paid to value in US health care, more attention should be paid to understanding the cost utility of TJA compared with nonoperative treatment modalities. Future studies may also look to incorporate patient willingness to pay.

Dataset Information

Risk stratification in primary total joint arthroplasty: the current state of knowledge.

Background

Methods

Results

Conclusions

Publications

Risk stratification in primary total joint arthroplasty: the current state of knowledge.

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