History of COVID-19 Was Not Associated With Length of Stay or In-Hospital Complications After Elective Lower Extremity Joint Replacement.
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ABSTRACT: Background
The impact of previous SARS-CoV-2 infection on the morbidity of elective total joint arthroplasty (TJA) is not fully understood. This study reports on the association between previous COVID-19 disease, hospital length of stay (LOS), and in-hospital complications after elective primary TJA.Methods
Demographics, comorbidities, LOS, and in-hospital complications of consecutive 340 patients with a history of COVID-19 were compared with those of 5014 patients without a history of COVID-19 undergoing TJA. History of COVID-19 was defined as a positive IgG antibody test for SARS-CoV-2 before surgery. All patients were given both antibody and polymerase chain reaction tests before surgery.Results
Patients with a history of COVID-19 were more likely to be obese (43.8% vs 32.4%, P < .001), Black (15.6% vs 6.8%, P < .001), or Hispanic (8.5% vs 5.4%, P = .028) than patients without a history of COVID-19. COVID-19 treatment was reported by 6.8% of patients with a history of COVID-19. Patients with a history of COVID-19 did not have a significantly longer median LOS after controlling for other factors (for hip replacements, median 2.9 h longer, 95% confidence interval = -2.0 to 7.8, P = .240; for knee replacements, median 4.1 h longer, 95% confidence interval = -2.4 to 10.5, P = .214), but a higher percentage were discharged to a post-acute care facility (4.7% vs 1.9%, P = .001). There was no significant difference in in-hospital complication rates between the 2 groups (0/340 = 0.0% vs 22/5014 = 0.44%, P = .221).Conclusions
We do not find differences in LOS or in-hospital complications between the 2 groups. However, more work is needed to confirm these findings, particularly for patients with a history of more severe COVID-19.Level of evidence
II.
SUBMITTER: Jungwirth-Weinberger A
PROVIDER: S-EPMC8660178 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Background This study evaluated risk factors associated with 30-day readmission after open and endovascular lower extremity revascularization. Methods Patients admitted with peripheral artery disease and lower extremity procedures were selected from national electronic medical record data, Cerner Health Facts® (2008-2014). Thirty-day readmission was determined. Logistic regression models identified characteristics independently associated with readmission. Results There were 2781 open and 2611 endovascular procedures. Readmission was 10.9% (9.6% open versus 12.3% endovascular, p<.0001). Greater disease severity was associated with readmission for both groups. Readmission factors for lower extremity bypass: blood transfusions (OR 2.25, 95% CI 1.62-3.13), hyponatremia (OR 1.72, 95% CI 1.15-2.57), heart failure (OR 1.57, 95% CI 1.07-2.29), bronchodilators (OR 1.50, 95% CI 1.13-2.00), black race (OR 1.43, 95% CI 1.03-1.99), and hypokalemia (OR 0.43, 95% CI 0.20-0.95). Readmission factors for endovascular procedures: vasodilators (OR 1.63, 95% CI 1.22-2.16), end-stage renal disease (OR 1.43, 95% CI 1.02-2.01), fluid and electrolyte disorders (OR 1.44, 95% CI 1.00-2.06), hypertension (OR 1.33, 95% CI 0.99-1.76), coronary artery disease (OR 1.31, 95% CI 1.02-1.67), and diuretics (OR 1.30, 95% CI 1.01-1.70). Conclusions Readmission after lower extremity revascularization is associated with disease severity for both procedures. Factors associated with readmission following lower extremity bypass included heart failure, transfusions, hyponatremia, black race, and bronchodilator use. Risk factors for endovascular readmissions were often chronic conditions including coronary artery disease, kidney disease, hypertension, and hypertensive medications. Awareness of risk factors may help providers identify high-risk patients who may benefit from increased surveillance and programs to lower readmission.
| S-EPMC5803457 | biostudies-literature
Project description:OBJECTIVES:To evaluate the ability of claims-based risk adjustment and incremental components of clinical data to identify 90-day episode costs among lower extremity joint replacement (LEJR) patients according to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) program provisions. DATA SOURCES:Medicare fee-for-service (FFS) data for qualifying CJR episodes in the United States, and FFS data linked with clinical data from CJR-qualifying LEJR episodes performed at High Value Healthcare Collaborative (HVHC) and Mayo Clinic in 2013. HVHC and Mayo Clinic populations are subsets of the total FFS population to assess the additive value of additional pieces of clinical data in correctly assigning patients to cost groups. STUDY DESIGN:Multivariable logistic models identified high-cost episodes. DATA COLLECTION/EXTRACTION METHODS:Clinical data from participating health care systems merged with Medicare FFS data. PRINCIPAL FINDINGS:Our three populations consisted of 363 621 patients in the CMS population, 4881 in the HVHC population, and 918 in the Mayo population. When modeling per CJR specifications, we observed low to moderate model performance (CMS C-Stat = 0.714; HVHC C-Stat = 0.628; Mayo C-Stat = 0.587). Adding CMS-HCC categories improved identification of patients in the top 20% of episode costs (CMS C-Stat = 0.758, HVHC C-Stat = 0.692, Mayo C-Stat = 0.677). Clinical variables, particularly functional status in the population for which this was available (Mayo C-Stat = 0.783), improved ability to identify patients within cost groups. CONCLUSIONS:Policy makers could use these findings to improve payment adjustments for bundled LEJR procedures and in consideration of new data elements for reimbursement.
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Project description:Our aim was to identify which patients are likely to stay in hospital longer following total hip replacement surgery. Longitudinal, observational study used routinely collected data. Data were collected from an NHS Trust in South-West England between 2016 and 2019. 2352 hip replacement patients had complete data and were included in analysis. Three measures of length of stay were used: a count measure of number of days spent in hospital, a binary measure of ≤7 days/>7 days in hospital and a binary measure of remaining in hospital when medically fit for discharge. The mean length of stay was 5.4 days following surgery, with 18% in hospital for more than 7 days, and 11% staying in hospital when medically fit for discharge. Longer hospital stay was associated with older age (OR=1.06, 95% CI 1.05 to 1.08), being female (OR=1.42, 95% CI 1.12 to 1.81) and more comorbidities (OR=3.52, 95% CI 1.45 to 8.55) and shorter length of stay with not having had a recent hospital admission (OR=0.44, 95% CI 0.32 to 0.60). Results were similar for remaining in hospital when medically fit for discharge, with the addition of an association with highest socioeconomic deprivation (OR=2.08, 95% CI 1.37 to 3.16). Older, female patients with more comorbidities and from more socioeconomically deprived areas are likely to remain in hospital for longer following surgery. This study produced regression models demonstrating consistent results across three measures of prolonged hospital stay following hip replacement surgery. These findings could be used to inform surgery planning and when supporting patient discharge following surgery.
| S-EPMC11340698 | biostudies-literature
Project description:ImportanceMedicare's Bundled Payments for Care Improvement (BPCI) initiative for lower extremity joint replacement (LEJR) surgery has been associated with a reduction in episode spending and stable-to-improved quality. However, BPCI may create unintended effects by prompting participating hospitals to increase the overall volume of episodes paid for by Medicare, which could potentially eliminate program-related savings or prompt them to shift case mix to lower-risk patients.ObjectiveTo evaluate whether hospital BPCI participation for LEJR was associated with changes in overall volume and case mix.Design, setting, and participantsObservational study using Medicare claims data and a difference-in-differences method to compare 131 markets (hospital referral regions) with at least 1 BPCI participant hospital (n = 322) and 175 markets with no participating hospitals (n = 1340), accounting for 580 043 Medicare beneficiaries treated before (January 2011-September 2013) and 462 161 after (October 2013-December 2015) establishing the BPCI initiative. Hospital-level case-mix changes were assessed by comparing 265 participating hospitals with a 1:1 propensity-matched set of nonparticipating hospitals from non-BPCI markets.ExposuresHospital BPCI participation.Main outcomes and measuresChanges in market-level LEJR volume in the before vs after BPCI periods and changes in hospital-level case mix based on demographic, socioeconomic, clinical, and utilization factors.ResultsAmong the 1 717 243 Medicare beneficiaries who underwent LEJR (mean age, 75 years; 64% women; and 95% nonblack race/ethnicity), BPCI participation was not significantly associated with a change in overall market-level volume. The mean quarterly market volume in non-BPCI markets increased 3.8% from 3.8 episodes per 1000 beneficiaries before BPCI to 3.9 episodes per 1000 beneficiaries after BPCI was launched. For BPCI markets, the mean quarterly market volume increased 4.4% from 3.6 episodes per 1000 beneficiaries before BPCI to 3.8 episodes per 1000 beneficiaries after BPCI was launched. The adjusted difference-in-differences estimate between the market types was 0.32% (95% CI, -0.06% to 0.69%; P = .10). Among 20 demographic, socioeconomic, clinical, and utilization factors, BPCI participation was associated with differential changes in hospital-level case mix for only 1 factor, prior skilled nursing facility use (adjusted difference-in-differences estimate, -0.53%; 95% CI, -0.96% to -0.10%; P = .01) in BPCI vs non-BPCI markets.Conclusions and relevanceIn this observational study of Medicare beneficiaries who underwent LEJR, hospital participation in Bundled Payments for Care Improvement was not associated with changes in market-level lower extremity joint replacement volume and largely was not associated with changes in hospital case mix. These findings may provide reassurance regarding 2 potential unintended effects associated with bundled payments for LEJR.
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Project description:BackgroundThe Comprehensive Care for Joint Replacement program implemented by the Centers for Medicare and Medicaid Services did not incorporate risk adjustment for lower extremity joint replacement (LEJR). Lack of adjustment places hospitals at financial risk and creates incentives for adverse patient selection.ObjectiveTo identify patient-level risk factors associated with health care utilization and costs of patients undergoing LEJR.MethodsA comprehensive search of research databases from January 1, 1990, through January 31, 2016, was conducted. The databases included Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and SCOPUS and is reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search identified 2020 studies. Eligible studies focused on primary unilateral and bilateral LEJR. Independent reviewers determined study eligibility and extracted utilization and cost data.ResultsSeventy-nine of 330 studies (24%) were included and were abstracted for analysis. Comorbidities, age, disease severity, and obesity were associated with increased costs. Increased number of comorbidities and age, presence of specific comorbidities, lower socioeconomic status, and female sex had evidence of increased length of stay. We found no significant association between indication for surgery and the likelihood of readmission.ConclusionDeveloping a risk adjustment model for LEJR that incorporates clinical variables may serve to reduce the likelihood of adverse patient selection and enhance appropriate reimbursement aligned with procedural complexity.
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Project description:ImportanceChanges in financial incentives have led to more patients being discharged home than to institutional forms of postacute care, such as skilled nursing facilities (SNFs), after elective lower extremity total joint replacement (LEJR).ObjectiveTo evaluate the association of this change with hospital readmissions, surgical complications, and mortality.Design, setting, and participantsThis cohort study used cross-temporal propensity-matching to identify 104 828 adult patients who were discharged home following LEJR between 2016 and 2018 (after changes in financial incentives) and 84 121 adult patients discharged to institutional forms of postacute care (eg, SNFs) between 2011 and 2013 (before changes in financial incentives). A difference-in-differences design was used to compare differences in outcomes between these groups to a propensity-matched group of patients discharged to institutional postacute care in both periods. Data were collected from Pennsylvania all-payer claims database, which includes all surgical procedures and hospitalizations across payers and hospitals in Pennsylvania. Data were analyzed between August 2019 and February 2020.ExposuresType of postacute care (home, including home with home health vs institutional postacute care, including SNF, inpatient rehabilitation facilities, and long-term acute care hospitals).Main outcomes and measuresMain outcomes were 30- and 90-day hospital readmissions, LEJR complication rates, and mortality rates.ResultsOf 189 949 patients, 113 981 (60.0%) were women, and 83 444 (43.9%) were aged 40 to 64 years. The rate of discharge home increased from 63.6% (54 097 of 85 121) in 2011 to 2013 to 78.4% (82 199 of 104 828) in 2016 to 2018. In the adjusted difference-in-differences comparison, matched patients discharged home in 2016 to 2018 had significantly lower 30-day (difference, -2.9%; 95% CI, -4.2% to -1.6%) and 90-day (difference, -3.9%; 95% CI, -5.8% to -2.0%) readmission rates compared with similar patients sent to institutional postacute care in 2011 to 2013. Surgical complication and mortality rates were unchanged. Results were similar across payers and across hospital bundled payment participation status.Conclusions and relevanceIn this cohort study, increases in discharges home following LEJR surgery did not seem to be associated with increased harm during a period in which changes in financial incentives likely spurred observed changes in postacute care.
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Project description:Importance:The associations of a family history of venous thromboembolism (FH-VTE) with postoperative venous thromboembolism (VTE) and major bleeding after joint replacement surgical procedures are unknown. Objective:To determine the risk of VTE and major bleeding in patients after primary hip or knee replacement surgical procedures. Design, Setting, and Participants:Cohort study using nationwide population-based databases of Swedish patients without a history of VTE who underwent joint replacement surgical procedures. Patients who had primary hip or knee replacement surgical procedures between July 1, 2005, and August 31, 2012, were identified. Patients born after 1931 without previous VTE were identified in the Swedish Multi-Generation Register. Only individuals with at least 1 parent and 1 full sibling alive between 1964 and the date for the surgical procedure were included. The data analysis was performed from September 1, 2017, to June 15, 2018. Exposures:Family history of VTE in a parent and/or a full sibling before the date of the surgical procedure. Main Outcomes and Measures:Venous thromboembolism and major bleeding within 90 days of the surgical procedure. Results:Of 69?505 study participants, 37?989 (54.7%) were women, and the median (interquartile range) age at the date of discharge was 65 (59-70) years. A total of 803 of 69?505 (1.2%) patients experienced postoperative VTE and 1285 (1.8%) experienced major bleeding. The cumulative VTE risk for those with FH-VTE was 231 of 15?858 (1.5%) and for those without an FH-VTE was 572 of 53?647 (1.1%) (P?<?.001). The cumulative bleeding risk for those with FH-VTE was 261 of 15?858 (1.6%) and for those without an FH-VTE was 1024 of 53?647 (1.9%) (P?=?.03). There was an association of patients with an FH-VTE who had increased VTE risk (adjusted hazard ratio [HR], 1.36; 95% CI, 1.17-1.59) and reduced bleeding risk (adjusted HR, 0.84; 95% CI, 0.74-0.97). There was an interaction between time after discharge and FH-VTE regarding VTE and major bleeding. An FH-VTE was not associated with VTE after discharge during the first week (HR, 1.13; 95% CI, 0.86-1.49). After 7 days from discharge, FH-VTE was associated with VTE (HR, 1.49; 95% CI, 1.24-1.79). An FH-VTE reduced major bleeding risk during the first 7 days after discharge (HR, 0.78; 95% CI, 0.66-0.91) but not thereafter (HR, 1.10; 95% CI, 0.84-1.44). Postoperative VTE heritability (SE) was 20% (6%). Conclusions and Relevance:Familial and most likely genetic factors appear to affect VTE and major bleeding risk following hip and knee replacement surgical procedures. Prolonged VTE prophylaxis might be beneficial in predisposed individuals. There may be a possible evolutionary advantage of prothrombotic genes protecting against traumatic bleeding.
| S-EPMC6324480 | biostudies-literature
Project description:Study designRetrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2010 that included 1861 patients who had undergone elective posterior lumbar fusion.ObjectiveTo characterize factors that were independently associated with increased hospital length of stay (LOS) in patients who had undergone elective posterior lumbar fusion.Summary of background dataPosterior lumbar spine fusion is a common surgical procedure used to treat lumbar spine pathology. LOS is an important clinical variable and a major determinant of inpatient hospital costs. There is lack of studies in the literature using multivariate analysis to examine specifically the predictors of LOS after elective posterior lumbar fusion.MethodsPatients who underwent elective posterior lumbar fusion from 2005 to 2010 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Preoperative and intraoperative variables were extracted for each case and a multivariate linear regression was performed to assess the contribution of each variable to LOS.ResultsA total of 1861 patients who had undergone elective posterior lumbar fusion were identified. The average age for patients in this cohort was 60.6 ± 13.9 years (mean ± standard deviation) with a body mass index of 30.3 ± 6.2 kg/m. Of the total patients, 44.7% of patients were male. LOS was in the range from 0 days to 51 days. Multivariate linear regression identified age (P < 0.001), morbid obesity (body mass index ≥ 40 kg/m, P < 0.001), American Society of Anesthesiologists class (P = 0.001), operative time (P < 0.001), multilevel procedure (P = 0.001), and intraoperative transfusion (P < 0.001) as significant predictors of extended LOS.ConclusionThe identified preoperative and intraoperative variables associated with extended LOS after elective posterior lumbar fusion may be helpful to clinicians for patient counseling and postoperative planning.Level of evidence3.
| S-EPMC3961012 | biostudies-literature
Project description:There is limited information on the impact on perioperative fluid intervention on complications and length of hospital stay following pancreaticoduodenectomy. Therefore, we conducted a detailed analysis of fluid intervention in patients undergoing pancreaticoduodenectomy at a university teaching hospital to test the hypothesis that a restrictive intravenous fluid regime and/or a neutral or negative cumulative fluid balance, would impact on perioperative complications and length of hospital stay.We retrospectively obtained demographic, operative details, detailed fluid prescription, complications and outcomes data for 150 consecutive patients undergoing pancreaticoduodenectomy in a university teaching hospital. Prognostic predictors for length of hospital stay and complications were determined.One hundred and fifty consecutive patients undergoing pancreaticoduodenectomy were evaluated between 2006 and 2012. The majority of patients were, middle-aged, overweight and ASA class III. Postoperative complications were frequent and occurred in 86 patients (57%). The majority of complications were graded as Clavien-Dindo Class 2 and 3. Postoperative pancreatic fistula occurred in 13 patients (9%), and delayed gastric emptying occurred in 25 patients (17%). Other postoperative surgical complications included sepsis (22%), bile leak (4%), and postoperative bleeding (2%). Serious medical complications included pulmonary edema (6%), myocardial infarction (8%), cardiac arrhythmias (13%), respiratory failure (8%), and renal failure (7%). Patients with complications received a higher median volume of intravenous therapy and had higher cumulative positive fluid balances. Postoperative length of stay was significantly longer in patients with complications (median 25 days vs. 10 days; p?<?0.001). After adjustment for covariates, a fluid balance of less than 1 litre on postoperative day 1 and surgeon caseloads were associated with the development of complications.In the context of pancreaticoduodenectomy, restrictive perioperative fluid intervention and negative cumulative fluid balance were associated with fewer complications and shorter length of hospital stay. These findings provide good opportunities to evaluate strategies aimed at improving perioperative care.
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Project description:BackgroundPostoperative complications are a significant source of morbidity and mortality. There are limited studies, however, assessing the impact of common postoperative complications on health care resource utilization.ObjectiveTo assess the association of clinically important postoperative complications with total hospital costs and length of stay (LOS) in patients undergoing noncardiac surgery.MethodsWe determined total hospital costs and LOS in all patients admitted to a single tertiary care center between July 1, 1996 and March 31, 1998 using a detailed administrative hospital discharge database. Total hospital costs and LOS were adjusted for preoperative and surgical characteristics.ResultsOf 7,457 patients who underwent noncardiac surgery, 6.9% developed at least 1 of the postoperative complications. These complications increased hospital costs by 78% (95% confidence interval [CI]: 68% to 90%) and LOS by 114% (95% CI: 100% to 130%) after adjustment for patient preoperative and surgical characteristics. Postoperative pneumonia was the most common complication (3%) and was associated with a 55% increase in hospital costs (95% CI: 42% to 69%) and an 89% increase in LOS (95% CI: 70% to 109%).ConclusionsPostoperative complications consume considerable health care resources. Initiatives targeting prevention of these events could significantly reduce overall costs of care and improve patient quality of care.
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