Perioperative population management for primary hip arthroplasty reduces hospital and postacute care utilization while maintaining or improving care quality

Study objectivePhysician-led multidisciplinary care coordination decreases hospital-associated care needs. We aimed to determine whether such care coordination can show benefits through the posthospital discharge period for elective hip surgery.DesignTime Series of prospectively recorded and historical data.SettingAcademic tertiary care medical center and health system.Patients449 patients undergoing elective primary hip surgery.InterventionsFor the intervention group we redesigned care with a comprehensive 14–16 week multidisciplinary standardized clinical pathway, the Ochsner hip arthroplasty perioperative surgical home (PSH). Essential pathway components were preoperative medical risk assessment, frailty scoring, home assessment, education and expectation setting. Collaborative team-based care, rigorous application of perioperative milestones, and proactive postoperative care coordination were key elements.MeasurementsThe intervention group was compared to historical controls with regard to demographics, risk factors, quality metrics, resource utilization and discharge disposition, the primary outcomes were hospital length of stay and postacute facility utilization.Main resultsCompared to historical controls, the intervention group had similar risk factors and the same or better quality outcomes. It had less combined skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) utilization compared to controls (16.5% vs. 27.5%). More intervention patients were discharged with home self-care compared to historical controls (10.7% vs 5.3%). During the intervention period combined SNF/IRF utilization decreased substantially from 19.8% early on, to 13.2% during a later phase. Intervention patients had fewer hospital days compared to historical controls (1.86 vs 3.34 days, respectively; P < 0.0001).ConclusionsA perioperative population management oriented care model redesign was effective in decreasing hospital days and postacute facility-based care utilization, while quality metrics were maintained or improved.     

Factors associated with post-acute functional status and discharge dispositions in individuals with spinal cord injury

BackgroundResearch has evaluated the effect of surgical timing on patient functional recovery in individuals with spinal cord injury (SCI); however, there is a critical need to assess how demographics, clinical characteristics, and process of care affect functional outcomes.ObjectiveWe examined the association between demographic, clinical, and process of care factors with post-acute functional status (locomotion and transfer mobility scores) and discharge disposition (home vs. institution) in individuals with SCI.MethodsThis study was a retrospective cohort analysis of the Pennsylvania Trauma Systems Outcomes Study (PTOS) database for individuals with traumatic SCI (N = 2223). We conducted multinomial and binomial logistic regression analyses to examine post-acute functional status and discharge disposition, respectively.ResultsThe results indicated that older age, longer length of stay, lower Glasgow Coma Scale (GCS), higher Injury Severity Score (ISS), and individuals with tetraplegia had significantly lower motor functional score at discharge from an acute hospital. In addition, older age, individuals with public-sponsored insurance, longer length of stay, lower GCS, and higher ISS had significantly higher odds of being discharged to an institution, as compared to home. Individuals of Hispanic ethnicity, as compared to White, had lower odds of being discharged to an institution.ConclusionsThe regression models developed in this study were able to better classify discharge destinations compared to the functional outcomes at discharge from the acute hospital. Further research is necessary to determine how these factors and their associations vary nationally across the US, which have the potential to inform trauma and acute care post-SCI.     

The Need for an Interpreter Increases Length of Stay and Influences Postoperative Disposition Following Primary Total Joint Arthroplasty

BackgroundMany US patients who undergo total joint arthroplasty have low English proficiency, yet no study has investigated how the need for a translator impacts postoperative outcomes for these patients. We hypothesized that need for an interpreter after total joint arthroplasty would impact discharge disposition and length of stay.MethodsWe performed a retrospective chart review of patients at a single large urban academic institution undergoing single primary total joint replacement from July 2016 to November 2019. Patients were classified as primarily English speaking (E), non-English primary language and did not require an interpreter (NE-N), or non-English primary language and did require an interpreter (NE-I). Data on patient characteristics, length of stay, and discharge disposition were collected.ResultsTotal hip arthroplasty (THA) patients in the NE-I group had significantly longer length of stay than both the NE-N group (2.85 vs 2.28 days, P = .015) and the E group (2.85 s vs 1.87 days, P < .0001). THA patients who required a translator were also significantly less likely to be discharged to home than those who were primarily English speaking (71.4% vs 88.8%, P < .0001). Total knee arthroplasty (TKA) patients in the NE-I group had significantly longer length of stay than the E group (2.66 vs 2.50 days, P = .009). The TKA patients in the NE-I group were significantly less likely to be discharged home than in the E group (74.5% vs 82.4%, P < .0001).ConclusionAlthough interpreter services are provided by the hospital for NE-I patients, the communication barrier that exists affects both length of stay and discharge disposition for both THA and TKA.     

Dementia is associated with increased mortality and poor patient-centered outcomes after vascular surgery

ObjectiveDementia has been associated with increased complications and mortality in orthopedics and other surgical specialties, but has received limited attention in vascular surgery. Therefore, we evaluated the association of dementia with surgical outcomes for elderly patients with Medicare who underwent a variety of open and percutaneous vascular surgery procedures.MethodsWe reviewed claims data from the Centers for Medicare and Medicaid Services for beneficiaries enrolled in Medicare Part A fee-for-service insurance from January 1, 2011, to December 31, 2011, who underwent inpatient vascular surgery. Only the first surgery during the first admission was considered for analysis. Traditional outcomes (30- and 90-day mortality, intensive care admission, complications, length of stay) and patient-centered outcomes (discharge to home, extended skilled nursing facility [SNF] stay, time at home) were adjusted for patient and procedure characteristics using multilevel linear or logistic regression as appropriate. All analyses were performed using SAS (v9.4, SAS Institute Inc, Cary, NC).ResultsOur study included 210,918 patients undergoing vascular surgery, of whom 27,920 carried a diagnosis of dementia. The average age of the entire cohort was 75.74 years, and 55.43% were male. Patients with dementia were older and had higher rates of comorbidities compared with patients without a dementia diagnosis. The three most common defined classes of intervention excluding miscellaneous ones were cerebrovascular, peripheral arterial, and aortic cases, which jointly accounted for 53.15% of cases. Among all cases, 56.62% were open. Emergent/urgent cases were more frequent amongst those with dementia (60.66% vs 37.93%; P < .001). After adjustment, patients with dementia had increased odds of 30-day mortality (odds ratio [OR], 1.21; P < .0001) and 90-day mortality (OR, 1.63; P < .0001), extended SNF stay (OR, 3.47; P < .0001), and longer hospital length of stay (8.29 days vs 5.41 days; P < .001). They were less likely to be discharged home (OR, 0.31; P < .0001) and spent a lower fraction of time at home after discharge (63.29% vs 86.91%; P < .001). Intensive care admission and inpatient complications were similar between the two groups.ConclusionsDementia is associated with poor traditional outcomes, including increased 30- and 90-day mortality and longer hospital lengths of stay in this large national patient sample. It is also associated with worse patient-centered outcomes, including substantially lower discharge rates to home, less time spent at home after discharge, and higher rates of extended stay in a SNF. These data should be used to counsel patients facing vascular surgery to provide goal-concordant care, particularly to patients with dementia.     

Distal femur fractures have a higher mortality rate compared to hip fractures among the elderly: Insights from the National Trauma Data Bank

IntroductionThe comparison of mortality and morbidity between distal femur (DF) and hip fracture in the old age is rarely reported in the literature. We aim to analyze a nationwide database among the elderly to compare the outcomes between hip fractures and distal femur fractures in the United States.Materials and MethodsA retrospective analysis of the National Trauma Data Bank was queried between 2007-2014 to identify distal femur (DF) and hip fracture patients greater than 65 years of age. Outcomes analyzed included in-hospital mortality, total hospital length of stay(LOS), intensive care unit length of stay(ICU-LOS), length of ventilation use and hospital discharge disposition. Multivariable regression models were performed to adjust for potential confounders. Statistical significance was established at p < 0.001.Results26,325 (10.1%) and 233,213 (89.9%) patients reported a diagnosis of DF and hip fracture, respectively. The inpatient mortality rate was significantly higher in the distal femur fracture group (8.3% vs. 6.7%), with significantly longer LOS (7.87 vs. 6.65), ICU-LOS (1.50 vs. 0.73), and required ventilation days (0.74 vs. 0.27). Multivariable analyses demonstrated that hip fracture patients had a lower mortality (adjusted odds ratio [aOR], 0.80; 95% CI [0.76, -0.85]; p < 0.001), shorter LOS ([aOR], -0.31; 95% CI [-0.39, -0.23]; P < 0.001), and more likely to be discharged home ([aOR], 0.88; 95% CI, 0.85, 0.91; P < 0.001, compared to DF fracture patients.ConclusionAfter adjusting for potential factors, DF fracture patients have a significantly higher mortality, longer LOS, and less likely to be discharged home compared to hip fractures among the elderly. These results may suggest clinicians and caregivers for closely monitoring of clinical conditions for these patients.Level of EvidenceIII.     

Factors implicated in discharge disposition following elective bariatric surgery

BackgroundCurrent bariatric surgery studies have focused on traditional outcomes such as mortality and morbidity and have thus far have neglected an important marker of surgical care- discharge destination.ObjectivesThe aim of this study was to 1) characterize the prevalence of and clinical characteristics of patients who undergo bariatric surgery with respect to discharge disposition and to 2) evaluate factors which predict alternate care facility (ACF) discharge.SettingParticipating Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) centers.MethodsData was extracted from the MBSAQIP data registry from 2015 to 2018. All primary Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were included while prior revisional surgeries and emergency surgeries were excluded. Our primary objective was to characterize the prevalence of and clinical characteristics of patients who undergo bariatric surgery and are discharged to an alternate care facility (ACF). Our secondary outcome was to identify predictors of discharge to an ACF using multivariable logistic regression modeling.ResultsMost patients (n = 588,256; 99.6%) were discharged home while only a small proportion were discharged to an ACF (n = 1502; .4%). Patients discharged to an ACF were older (51.5 ± 13.5 yr versus 44.4 ± 12.0 yr; P < .0001), of increased body mass index (49.7 ± 11.9 kg/m² versus 45.3 ± 7.8 kg/m²; P < .0001), and more likely to be of male sex (26.8% versus 20.4%; P < .0001). Patients with hypertension (65.2% versus 47.9%; P < .0001), dyslipidemia (40.1% versus 23.7%; P < .0001), sleep apnea (52.7% versus 38.1%; P < .0001), and medication-dependent diabetes (39.5% versus 26.3%; P < .0001) were more likely to be discharged to an ACF. Multivariable logistic regression revealed that partially dependent and dependent functional status were the single greatest preoperative predictors of ACF discharge with an 8- and 7-fold respective increase in odds of ACF versus patients of independent functional status.ConclusionImpaired functional status was the single greatest independent preoperative predictor of ACF discharge, providing evidence against the current use of a strict age cut-off criteria and support for implementation of a more patient-centered functional approach in selection of surgical candidates.     

Traumatic spinal cord injury in West Virginia: Disparities by insurance and discharge disposition from an acute care hospital

Context: Medicaid has been linked to worse outcomes in a variety of diagnoses such as lung cancer, uterine cancer, and cardiac valve procedures. It has furthermore been linked to the reduced health-related quality of life outcomes after traumatic injuries when compared to other insurance groups. In spinal cord injury (SCI), the care provided in the subacute setting may vary based upon payor status, which may have implications on outcomes and cost of care.

Design: A retrospective review utilizing the institutional trauma databank was performed for all adult patients with spinal cord injury since 2009. Pediatric patients were excluded. Insurance type, race, length of stay, discharge status (alive/dead), discharge disposition, injury severity score (ISS), and hospital charges billed were recorded.

Results: Two hundred patients were identified. Overall 27.5% of patients with SCI during the period of our review were Medicaid beneficiaries. ISS was similar between Medicaid and non-Medicaid patients, but the Medicaid beneficiaries were younger (37 vs 50 years of age; P?<?.001). Medicaid beneficiaries had a significantly longer length of stay (20.9 days; P?<?.001) when compared to all other patients. They furthermore were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center. Inpatient charges billed for Medicaid beneficiaries were significantly higher than those of non-Medicaid patients (203,264 USD vs 140,114 USD; P?=?.015), likely reflecting the increased length of stay while awaiting appropriate disposition.

Conclusion: Medicaid patients with SCI in West Virginia had a longer hospital stay, higher charges billed, and were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center, when compared to non-Medicaid patients. The lack of availability of rehabilitation facilities for Medicaid beneficiaries likely explains this difference.     

Twenty-Three-Hour-Stay Colectomy Without Increased Readmissions: An Analysis of 1905 Cases from the National Surgical Quality Improvement Program

Background

Isolated case series from highly specialized centers suggest the feasibility of a 23-h hospital stay after colectomy. We sought to determine preoperative variables associated with discharge within 23 h after colectomy to identify patients best suited for a short-stay model.

Methods

The American College of Surgeons NSQIP Colectomy-Targeted database was used to identify patients who underwent elective colectomy from 2012 to 2017. All cases with missing length of stay or inpatient death were excluded. Patients with a postoperative hospital stay ≤1 day were identified. Univariate and multivariate analyses were conducted to identify factors associated with early discharge.

Results

A total of 1905 patients were discharged within 23 h after surgery (1.6%). These patients were noted to be younger (59 versus 61 years, p < 0.001) and less likely to have insulin-dependent diabetes (3.0 versus 4.4%, p < 0.001), preoperative dyspnea (2.2 versus 6.0%, p < 0.001), COPD (3.0 versus 4.2%, p = 0.011), and hypertension (40.7 versus 46.9%, p < 0.001) than patients who stayed longer. Shorter operative time (OR 0.986, 95% CI 0.985–0.987, p < 0.001), minimally invasive techniques (OR 2.969, 95% CI 2.686–3.282, p < 0.001), lack of ostomy (OR 0.614, 95% CI 0.478–0.788, p < 0.001), and lack of ureteral stenting (OR 0.641, 95% CI 0.500–0.821, p < 0.001) were associated with early discharge in multivariable analysis. There was no increased incidence of readmission in patients discharged within 23 h.

Conclusions

Twenty-three-hour-stay colectomy is feasible on a national level and does not result in an increased incidence of readmission. Patients undergoing elective procedures without significant medical comorbidities may be eligible for early discharge. Preoperative factors may be used to select patients best suited for this short-stay model.

     

Post-discharge rehabilitation and functional recovery after pediatric injury

IntroductionVariability in rehabilitation disposition has been proposed as a trauma center quality metric. Benchmarking rehabilitation disposition is limited by a lack of objective measures of functional impairment at discharge. The primary aim of this study was to determine the relative contribution of patient characteristics and hospitalization factors associated with inpatient and outpatient rehabilitation after discharge. The secondary aims were to evaluate the sensitivity of the Functional Status Scale (FSS) score for identifying functional impairments at hospital discharge and track post-discharge recovery.Patients and methodsWe report a planned secondary analysis of a prospective observational study of seriously injured children (<15 years old) enrolled at seven pediatric trauma centers. Functional Status Scale (FSS) score was measured for pre-injury, hospital discharge, and 6-month follow-up timepoints. Multinomial logistic regression identified factors associated with three dispositions: home without rehabilitation services, home with outpatient rehabilitation, and inpatient rehabilitation. Relative weight analysis was used to identify the impact of individual factors associated with inpatient or outpatient rehabilitation disposition.ResultsWe analyzed 427 children with serious injuries. Functional impairment at discharge was present in 103 (24.1%) children, including 43/337 (12.8%) discharged without services, 12/38 (31.6%) discharged with outpatient rehabilitation, and 44/47 (93.6%) discharged to inpatient rehabilitation. In multivariable modeling, variables most contributing to prediction of inpatient rehabilitation were severe initial Glasgow coma scale (GCS), injured body region, and functional impairment at discharge. Severe initial GCS, private insurance, and extremity injury were independently associated with disposition with outpatient rehabilitation. Patients discharged without services or with outpatient rehabilitation most frequently had motor impairments that improved during the next 6 months. Patients discharged to inpatient rehabilitation had impairments in all domains, with many improving within 6 months. A higher proportion of patients discharged to inpatient rehabilitation had residual impairments at follow-up.ConclusionInjury characteristics and discharge impairment were associated with discharge to inpatient rehabilitation. The FSS score identified impairments needing inpatient rehabilitation and characterized improvements after discharge. Less severe impairments needing outpatient rehabilitation were not identified by the FSS score.     

Disparities in discharge patterns of admitted older patients with ocular trauma

PurposeIn older patients, poor vision from ocular trauma increases the likelihood of further injuries and repeat hospitalizations, underscoring the need for appropriate post-hospitalization care. We sought to evaluate disposition patterns of older patients admitted with ocular trauma.Methods/MaterialsThis retrospective observational study analyzed the National Trauma Data Bank (2008–2014) and de-identified data of patients, ≥65 years old, admitted with ocular trauma were identified using ICD-9CM and E-codes. Age, gender, race/ethnicity, type of ocular injury, comorbidities, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, length of hospital stay, location and US region, insurance, and discharge disposition were extracted. Analysis was performed with student's t-test, Chi-squared test, and odds ratios (OR) using SPSS software. Statistical significance was set at P <.05.Results58,074 (18.3%) of 316,485 patients admitted with ocular trauma were >65yrs. 26,346 (45.4%) were discharged home and 23,314 (40.1%) to an advanced care facility (ACF). Nursing home residents were most likely to return to ACF (OR, 4.76; 95%CI, 4.40–5.14; P < .001). Patients with severe traumatic brain injury (Glasgow coma score [GCS]<8) (OR, 4.57; 95%CI, 4.09–5.11; P < .001), very severe injury severity score (ISS ≥24) (OR, 3.73; 95%CI, 3.46–4.01; P < .001), females (OR, 1.27; 95%CI, 1.23–1.32; P < .001), white patients (OR, 1.29; 95%CI, 1.24–1.36; P < .001) and Medicare beneficiaries (OR, 1.14; 95%CI, 1.09–1.19; P < .001) were most likely to be discharged to an ACF. Demography-related discharge propensities prevailed nationwide and within insurance categories. Multivariate regression analysis revealed factors determining ACF placement were, in order: length of hospital stay, nursing home residency, GCS<8, ISS>24, female gender, white race, and Medicare insurance.ConclusionsHispanic, black, male, and self-paying patients were disproportionately discharged home. Ocular injuries had low impact on ACF placement. Understanding these disparities will assist in developing guidelines for appropriate and equitable post-trauma rehabilitation in this vulnerable population.     

Disparities in disposition from trauma centers to inpatient psychiatric treatment in a national sample of patients with self-inflicted injury

BackgroundSurgery providers are integral to the treatment of patients with self-inflicted injuries. Patient disposition (eg, home, inpatient psychiatric treatment, rehabilitation) is important to long-term outcomes, but little is known about factors influencing disposition after discharge following traumatic self-inflicted injury. We tested whether patient or injury characteristics were associated with disposition after treatment for self-inflicted injury.MethodsNational Trauma Data Bank query for self-inflicted injuries from 2010 to 2018.ResultsThere were 77,731 patients treated for self-inflicted injuries during the study period. Discharge home was the most common disposition (45%), and those without insurance were less likely to discharge to inpatient psychiatric treatment than those with insurance. Racial minority patients were less likely to discharge to inpatient psychiatric treatment (18.9%) than nonminority patients (23.8%, P < .001). Additionally, patients discharged to inpatient psychiatric treatment had significantly lower injury severity score (7.24 ± 7.5) than those who did not (8.69 ± 9.1, P < .001).ConclusionRacial/ethnic minority patients and those without insurance were significantly less likely to discharge to an inpatient psychiatric facility after treatment at a trauma center for self-inflicted injury. Future research is needed to evaluate the internal factors (eg, trauma center practices) and external factors (eg, inpatient psychiatric facilities not accepting patients with wound care needs) driving disposition variability.     

Short-term Morbidity and Readmissions Increase With Skilled Nursing Facility Discharge After Total Joint Arthroplasty in a Medicare-Eligible and Skilled Nursing Facility–Eligible Patient Cohort

Background

The benefits of discharge to a skilled nursing facility (SNF) in Medicare-eligible patients after total joint arthroplasty (TJA) have recently been scrutinized. The purpose of this study was to determine short-term complication and readmission rates for SNF versus home discharge in patients eligible for Medicare and SNF discharge.

Home Discharge Has Increased After Total Hip Arthroplasty,However Rates Vary Between Large Databases

BackgroundThere have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA.MethodsPatients undergoing primary THA were identified using International Statistical Classification of Diseases and Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed.ResultsIn ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 (P < .0001). In Humana, 84,832 THA patients were identified, with an increase in home discharge from 56.6% to 72.8% (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and nonhome going patients. Patients discharged home had a decrease in readmissions in both databases.ConclusionPatients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.     

Factors Determining Discharge Destination for Patients Undergoing Total Joint Arthroplasty

Discharge destination to skilled nursing facilities (SNF) following total joint arthroplasty (TJA) plays an important role in healthcare costs. The pre-operative, intra-operative, and post-operative factors of 50 consecutive patients discharged to an SNF following TJA were compared to that of 50 consecutive patients discharged to home. Patients discharged to SNFs had slower pre-operative Get Up and Go scores (TGUG), lower pre-operative EQ-5D scores, higher ASA scores, increased hospital length of stay, increased self-reported post-operative pain, and decreased physical therapy achievements. We believe that the results of this study indicate that patients who get discharged to SNFs fit a certain criteria and this may be used to guide post-operative discharge destination during pre-operative planning, which can help lower costs while helping decrease the length of inpatient stay.     

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care “Value”

BackgroundValue is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF).MethodsBetween October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01).ResultsThere were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001).ConclusionAmong Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.     

Risk factors for nonroutine discharge in adult spinal deformity surgery

BACKGROUND CONTEXTSurgery for adult spinal deformity (ASD) is increasingly common. Although outcomes of ASD surgery have been studied extensively, to our knowledge, no data exist regarding factors predicting nonroutine discharge in this population. Nonroutine discharge is defined as discharge to a health care facility after surgery rather than to home.PURPOSETo determine which patient and surgical factors predict nonroutine discharge after ASD surgery.DESIGNThis is a retrospective study.PATIENTS SAMPLEWe conducted a retrospective single-center study of 303 patients who underwent arthrodesis of five or more spinal levels to treat ASD between 2009 and 2014.OUTCOME MEASURESPatients were stratified into two groups according to discharge disposition: home or nonroutine.METHODSObjective preoperative characteristics, intraoperative course, and postoperative recovery were analyzed to identify pre- and perioperative factors associated with nonroutine discharge. Univariate analysis was performed first. All factors with P values < .2 on univariate analysis were included in a logistic regression model. Additionally, to understand the relationship between subjective patient-reported outcome measures and nonroutine discharge, we compared the two groups with respect to mean Oswestry Disability Index and Scoliosis Research Society-22r domains using Student t-tests.RESULTSOn univariate analysis, objective measures that differed significantly (P < .05) between the two cohorts were age (≥65 years), osteoporosis, Charlson Comorbidity Index score of ≥2, prolonged hospital stay (>8 days), and blood transfusion. Given the above logistic regression inclusion criteria, we controlled for the performance, and type, of osteotomy (P = .055). On multivariate analysis, older age, osteoporosis, prolonged hospital stay, blood transfusion, and 3-column osteotomy were independently associated with nonroutine discharge. Subjective patient-reported outcome measures, including Oswestry Disability Index and Scoliosis Research Society-22r physical function and pain domain scores, were significantly worse in the nonroutine discharge cohort (P < .05).CONCLUSIONTo our knowledge, this is the first study to evaluate pre- and perioperative factors associated with nonroutine discharge after ASD surgery. Elderly patients who undergo complex surgery and receive blood transfusions are at particularly high risk of nonroutine discharge. Surgeons should consider these factors during surgical planning and preoperative patient counseling.     

A comparison of patient same-day discharge selection after shoulder arthroplasty before and after the COVID-19 pandemic

BackgroundEarly discharge has been a target of cost control efforts, given the growing demand for joint replacement surgery. Select patients are given the choice for same-day discharge (SDD) or overnight stay after shoulder arthroplasty. The COVID-19 pandemic changed patient perspectives regarding hospital visitation and admission. The purpose of this study was to determine if the COVID-19 pandemic impacted the utilization of SDD after shoulder arthroplasty. We hypothesize that patients undergoing shoulder arthroplasty after the start of the COVID-19 pandemic will have higher rates of SDD.MethodsA retrospective continuous review was performed on 370 patients who underwent a primary anatomic (total shoulder arthroplasty) or reverse shoulder arthroplasty between August 2019 and December 2020 by a single surgeon. This group of patients represent the 185 arthroplasty cases completed before the COVID-19 pandemic and the first 185 patients after the start of the pandemic. April 1, 2020, was chosen as the cutoff for pre-COVID patients, as this represents the date a statewide ban on elective surgery was declared. All patients were counseled preoperatively regarding SDD and given the choice to stay overnight, unless medically contraindicated. Demographics, medical history, length of stay, 30- and 90-day readmissions, and 90-day emergency room (ER) and urgent care visits were obtained from medical records and compared. Two-tailed student t-tests, chi-square tests, and Fischer’s exact were performed where appropriate.ResultsThe 2 groups were similar in age, body mass index, gender distribution, and Outpatient Arthroplasty Risk Assessment score. During the collection period, there were more anatomic shoulder arthroplasties performed after (54%) than before (44%) the COVID-19 pandemic (P = .029). Patients treated after the start of the COVID-19 pandemic were almost 3 times more likely to have an SDD (P < .001), with 85.4% (158/185) of patients being discharged the same day after COVID-19, compared with 34.6% (64/185) before COVID-19. Discharge disposition (location of discharge) was significantly different, as 99% (183/185) of patients undergoing surgery after the start of the COVID-19 pandemic were discharged home, compared with 94% (174/185) of patients before COVID-19. There was no difference in 30-day readmissions, 90-day readmissions, and 90-day (ER) and urgent care visits between the 2 groups.ConclusionOur study suggests that the COVID-19 pandemic has dramatically impacted patient choices for SDD within a single surgeon’s practice, with nearly 3 times as many patients electing for SDD. Readmissions and ER visits were similar, indicating that SDD remains a safe alternative for patients after total shoulder arthroplasty and reverse shoulder arthroplasty.Level of evidenceLevel III; Retrospective Comparative Study     

Preexisting psychiatric illness worsens acute care outcomes after orthopaedic trauma in obese patients

PurposePre-existing psychiatric illness, illicit drug use, and alcohol abuse adversely impact patients with orthopaedic trauma injuries. Obesity is an independent factor associated with poorer clinical outcomes and discharge disposition, and higher hospital resource use. It is not known whether interactions exist between pre-existing illness, illicit drug use and obesity on acute trauma care outcomes.Patients and methodsThis cohort study is from orthopaedic trauma patients prospectively measured over 10 years (N = 6353). Psychiatric illness, illicit drug use and alcohol were classified by presence or absence. Body mass index (BMI) was analyzed as both a continuous and categorical measure (<30 kg/m² [non-obese], 30–39.9 kg/m² [obese] and ≥40 kg/m² [morbidly obese]). Main outcomes were the number of acute care services provided, length of stay (LOS), discharge home, hospital readmissions, and mortality in the hospital.ResultsStatistically significant BMI by pre-existing condition (psychiatric illness, illicit drug use) interactions existed for LOS and number of acute care services provided (β values 0.012–0.098; all p < 0.05). The interaction between BMI and psychiatric illness was statistically significant for discharge to locations other than home (β = 0.023; p = 0.001).DiscussionObese patients with orthopaedic trauma, particularly with preexisting mental health conditions, will require more hospital resources and longer care than patients without psychiatric illness. Early identification of these patients through screening for psychiatric illness and history of illicit drug use at admission is imperative to mobilize the resources and provide psychosocial support to facilitate the recovery trajectory of affected obese patients.     

Adult Trauma Patients with Autism Spectrum Disorder: A Case-Control Study to Evaluate Disparities After Injury

BackgroundAdult trauma patients with autism spectrum disorder (ASD) may have distinct care needs that have not been previously described. We hypothesized that due to differences in clinical care and disposition issues, injured adults with ASD would have increased lengths of stay, higher mortality, and increased rates of complications compared to adults without ASD.MethodsThe Pennsylvania Trauma Outcomes Study database was queried from 2010-2018 for trauma patients with ASD. Case-control matching was performed for two controls per ASD patient accounting for age, gender, injury mechanism, and injury severity score. Primary outcomes included length of stay, mortality, and complication rate. Univariate analysis compared presentation and clinical care between the two groups. Multivariate regression and Kaplan-Meier curves modeled length of stay. Significance was defined as p < 0.05.ResultsA total of 185 patients with ASD were matched to 370 controls. Age (mean +/- standard deviation) was 33.4 +/- 16.5 years. Gender was 81.1% male. Mechanisms were 88.1% blunt, 5.9% penetrating, and 5.9% burns. Significant clinical differences identified in patients with ASD vs. case-controls included presenting verbal GCS (median [IQR]) (5 [2] vs. 5 [0], p < 0.01), proportion of patients intubated at presentation (20.0% vs. 13.0%, p = 0.031), and hospital length of stay (4 [6] days vs. 3 [4] days, p = 0.002). Adult patients with ASD were less likely to be discharged home and more often discharged to a skilled nursing facility (p < 0.01). There were no differences in mortality, rates of complications, imaging, or operations. Multivariate regression analysis controlling for demographic and clinical differences revealed the diagnosis of ASD independently contributed 3.13 days (95% Confidence Interval: 1.85 to 4.41 days) to injured adults’ length of stay. Kaplan-Meier curves showed injured patients with ASD were less likely to be discharged than case-controls starting from time of admission (log rank test, p < 0.001).ConclusionsThis statewide analysis suggests injured patients with ASD have increased lengths of stay without other clinical or outcome differences. Given significant differences in discharge destination, these findings support early involvement of a multidisciplinary care collaborative. Further research is needed to identify factors that contribute to disparities in care for adults with ASD.