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1.
Jeffrey B. Stambough Denis Nam David K. Warren James A. Keeney John C. Clohisy Robert L. Barrack Ryan M. Nunley 《The Journal of arthroplasty》2017,32(3):728-734.e1
Background
Staphylococcus aureus colonization has been identified as a key modifiable risk factor in the reduction of surgical site infections (SSI) related to elective total joint arthroplasty (TJA). We investigated the incidence of SSIs and cost-effectiveness of a universal decolonization protocol without screening consisting of nasal mupirocin and chlorhexidine before elective TJA compared to a program in which all subjects were screened for S aureus and selectively treated if positive.Methods
We reviewed 4186 primary TJAs from March 2011 through July 2015. Patients were divided into 2 cohorts based on the decolonization regimen used. Before May 2013, 1981 TJA patients were treated under a “screen and treat” program while the subsequent 2205 patients were treated under the universal protocol. We excluded the 3 months around the transition to control for treatment bias. Outcomes of interest included SSI and total hospital costs.Results
With a universal decolonization protocol, there was a significant decrease in both the overall SSI rate (5 vs 15 cases; 0.2% vs 0.8%; P = .013) and SSIs caused by S aureus organisms (2 vs 10; 0.09% vs 0.5%; P = .01). A cost analysis accounting for the cost to administer the universal regimen demonstrated an actual savings of $717,205.59. TJA complicated by SSI costs 4.6× more to treat than that of an uncomplicated primary TJA.Conclusion
Our universal decolonization paradigm for elective TJA is effective in reducing the overall rate of SSIs and promoting economic gains for the health system related to the downstream savings accrued from limiting future reoperations and hospitalizations. 相似文献2.
Jared M. Newman Caleb R. Szubski Wael K. Barsoum Carlos A. Higuera Robert M. Molloy Trevor G. Murray 《The Journal of arthroplasty》2017,32(1):11-15
Background
Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).Methods
An administrative clinical database at a large US health care system was reviewed for all primary THA and TKA admissions performed between 2010 and 2012 (n = 15,237). Of these, 14,800 cases met our inclusion criteria and were analyzed. Furthermore, the cohort was divided into early (Monday/Tuesday) and late week (Thursday/Friday) surgeries, excluding Wednesday surgeries (n = 2835). Univariate and multiple regression analyses examined the effect of each variable on LOS.Results
Mean LOS for THA and TKA on Monday was 3.54 and 3.35 days and increased to 4.12 and 3.66 days on Friday (P < .0001), respectively. Late vs early week admissions had 0.358 (95% confidence interval: 0.29-0.425, P < .001) additional hospital days. Increased age (0.003 days per unit increase in age, P = .02) and severity of illness score (0.781 days per level increase, P < .001) were associated with increased LOS. Late week surgery had a greater effect on LOS for TKA than for THA. TKAs were associated with higher charges for late week surgery vs early week surgery (P < .001).Conclusion
Late week TJA cases, older age, and increasing severity of illness score were associated with increased LOS. Furthermore, late week TKA was associated with increased total charges. 相似文献3.
Shawn Sahota Francis Lovecchio Ryan E. Harold Matthew D. Beal David W. Manning 《The Journal of arthroplasty》2018,33(1):30-35
Background
Total joint arthroplasty (TJA) is a highly successful treatment, but is burdensome to the national healthcare budget. National quality initiatives seek to reduce costly complications. Smoking's role in perioperative complication after TJA is less well known. This study aims to identify smoking's independent contribution to the risk of short-term complication after TJA.Methods
All patients undergoing primary TJA between 2011 and 2012 were selected from the American College of Surgeon's National Surgical Quality Improvement Program's database. Outcomes of interest included rates of readmission, reoperation, mortality, surgical complications, and medical complications. To eliminate confounders between smokers and nonsmokers, a propensity score was used to generate a 1:1 match between groups.Results
A total of 1251 smokers undergoing TJA met inclusion criteria. Smokers in the combined total hip and knee arthroplasty cohort had higher 30-day readmission (4.8% vs 3.2%, P = .041), were more likely to have a surgical complication (odds ratio 1.84, 95% confidence interval 1.21-2.80), and had a higher rate of deep surgical site infection (SSI) (1.1% vs 0.2%, P = .007).Analysis of total hip arthroplasty only revealed that smokers had higher rates of deep SSI (1.3% vs 0.2%, P = .038) and higher readmission rate (4.3% vs 2.2%, P = .034). Analysis of total knee arthroplasty only revealed greater surgical complications (2.8% vs 1.2%, P = .048) and superficial SSI (1.8% vs 0.2%, P = .002) in smokers.Conclusion
Smoking in TJA is associated with higher rates of SSI, surgical complications, and readmission. 相似文献4.
David N. Bernstein Tiffany C. Liu Angela L. Winegar Lauren W. Jackson Jessica L. Darnutzer Kelsey M. Wulf John T. Schlitt Mauricio A. Sardan Kevin J. Bozic 《The Journal of arthroplasty》2018,33(12):3642-3648
Background
Preoperative optimization of risk factors has been suggested as a strategy to improve the value of total joint arthroplasty (TJA) care. We assessed the implementation of a TJA preoperative optimization protocol and its impact on length of hospital stay, discharge destination, 90-day readmissions, and hospital direct variable costs.Methods
This retrospective cohort study included adults undergoing primary elective TJA from 07/2015-09/2016 at an urban tertiary care hospital. Post-implementation patients were preoperatively screened for 19 risk factors; results and recommended interventions were reported to surgeons, who had the option to postpone or continue surgery as scheduled. Metrics from hospital administrative databases were compared between post-implementation (02/2016-09/2016) and pre-implementation cohorts (07/2015-11/2015).Results
The 314 post-implementation patients were slightly younger compared to the 351 pre-implementation patients (64.2 years vs 65.8 years, P = .02) and a higher percentage of patients had diabetes (18% vs 5.1%, P < .001). Of the 98% of post-implementation patients screened, 74% had at least 1 risk factor identified. Obstructive sleep apnea was the most common risk factor (52%), followed by depression (22%) and obesity (body mass index > 40 kg/m2 or 35-40 kg/m2 with comorbidities) (13%). Forty-six patients (20%) did not follow through with the recommended optimization before undergoing elective surgery. The post-implementation cohort had shorter average length of hospital stay (1.9 days vs 2.2 days, P < .001) and lower average total direct variable costs excluding implants ($5409 vs $5852, P < .001). There was no difference in patients discharged home (90% vs 89%, P = .53) or 90-day readmissions (4.1% vs 4.3%, P = .93).Conclusion
In our experience, the majority of elective TJA patients have modifiable risk factors, indicating opportunity for preoperative intervention. Our evidence-based preoperative optimization program resulted in higher value care, demonstrated by similar outcomes with lower resource utilization. 相似文献5.
Udai S. Sibia Abigail E. Mandelblatt Maura A. Callanan James H. MacDonald Paul J. King 《The Journal of arthroplasty》2017,32(2):381-385
Background
Unplanned hospital returns after total joint arthroplasty (TJA) reduce any cost savings in a bundled reimbursement model. We examine the incidence, risk factors, and costs for unplanned emergency department (ED) visits and readmissions within 30 days of index TJA.Methods
We retrospectively reviewed a consecutive series of 655 TJAs (382 total knee arthroplasty and 273 total hip arthroplasty) performed between April 2014 and March 2015. Preoperative diagnosis was osteoarthritis of the hip or knee (97%) or avascular necrosis of the hip (3%). Hospital costs were recorded for each ED visit and readmission episode.Results
Of the 655 TJAs reviewed, 55 (8.4%) returned to the hospital. Of these hospital returns, 35 patients (5.3%) returned for a total of 36 unplanned ED visits whereas the remaining 20 patients (3.1%) presented 22 readmissions within 30 days of index TJA. The 2 most common reasons for unplanned ED visits were postoperative pain/swelling (36%) and medication-related side effects (22%). Avascular necrosis of the hip was a significant risk factor for an unplanned ED visit (7.27 odds ratio [OR], 95% confidence interval [CI] 1.67-31.61, P = .008). Multiple logistic regression analysis revealed the following risk factors for readmission: body mass index (1.10 OR, 95% CI 1.02-1.78, P = .013), comorbidity >2 (2.07 OR, 95% CI 1.06-6.95, P = .037), and prior total knee arthroplasty (2.61 OR, 95% CI 1.01-6.72, P = .047). Ambulating on the day of surgery trended toward a lower risk for readmission (0.13 OR, 95% CI 0.02-1.10, P = .061). The 2 most common reasons for readmission were ileus (23%) and cellulitis (18%). The total cost associated with unplanned ED visits were $15,427 whereas costs of readmissions totaled $142,654.Conclusion
Unplanned ED visits and readmissions in the forthcoming bundled payments reimbursement model will reduce cost savings from rapid recovery protocols for TJA. Identifying and mitigating preventable causes of unplanned visits and readmissions will be critical to improving care and controlling costs. 相似文献6.
Jonathan W. Cheah David C. Sing Erik N. Hansen Pedram Aleshi Thomas P. Vail 《The Journal of arthroplasty》2018,33(6):1693-1698
Background
Intrathecal morphine (ITM) combined with bupivacaine spinal anesthesia can improve postoperative pain, but has potential side effects of postoperative nausea/vomiting (PONV) and pruritus. With the use of multimodal analgesia and regional anesthetic techniques, postoperative pain control has improved significantly to a point where ITM may be avoided in total joint arthroplasty (TJA).Methods
We performed a retrospective study of primary TJA patients who underwent a standardized multimodal recovery pathway and received bupivacaine neuraxial anesthesia with ITM vs bupivacaine neuraxial anesthesia alone (control).Results
In total, 598 patients were identified (131 controls, 467 ITMs) with similar demographics. On postoperative day 0 (POD 0), ITM patients had significantly lower mean visual analog scale scores (1.5 ± 1.6 vs 2.5 ± 1.9, P < .001) and consumed less oral morphine equivalents (10.5 ± 25.4 vs 16.8 ± 27.2, P = .013). ITM patients walked further compared to controls by POD 1 (133.6 ± 159.6 vs 97.3 ± 141 m, P = .028) and were less likely to develop PONV during their entire hospital stay (38.5% vs 48.6%, P = .043). No significant differences were seen for total morphine equivalents consumption, rate of discharge to care facility, length of stay, and 90-day readmission rates.Conclusion
ITM was associated with improved POD 0 pain scores and less initial oral/intravenous opioid consumption, which likely contributes to the subsequent improved mobilization and lower rates of PONV. In the setting of a modern regional anesthesia and multimodal analgesia recovery plan for TJA, ITM can still be considered for its benefits. 相似文献7.
Suparna M. Navale Caleb R. Szubski Alison K. Klika Nicholas K. Schiltz Pratik P. Desai Wael K. Barsoum 《The Journal of arthroplasty》2017,32(4):1107-1116.e1
Background
As the prevalence of and life expectancy after solid organ transplantation increases, some of these patients will require total hip arthroplasty (THA). Immunosuppressive therapy, metabolic disorders, and post-transplant medications may place transplant patients at higher risk of adverse events following surgery. The objective of this study was to compare inpatient complications, mortality, length of stay (LOS), and costs for THA patients with and without solid organ transplant history.Methods
A retrospective cross-sectional analysis was conducted using 1998-2011 Nationwide Inpatient Sample. Primary THA patients were queried (n = 3,175,456). After exclusions, remaining patients were assigned to transplant (n = 7558) or non-transplant groups (n = 2,772,943). After propensity score matching, adjusted for patient and hospital characteristics, logistic regression and paired t-tests examined the effect of transplant history on outcomes.Results
Between 1998 and 2011, THA volume among transplant patients grew approximately 48%. The overall prevalence of one or more complications following THA was greater in the transplant group than in the non-transplant group (32.0% vs 22.1%; P < .001). In-hospital mortality was minimal, with comparable rates (0.1%) in both groups (P = .93). Unadjusted trends show that transplant patients have greater annual and overall mean LOS (4.47 days) and mean admission costs ($18,402) than non-transplant patients (3.73 days; $16,899; P < .001). After propensity score matching, transplant history was associated with increased complication risk (odds ratio, 1.56) after THA, longer hospital LOS (+0.64 days; P < .001), and increased admission costs (+$887; P = .005).Conclusion
Transplant patients exhibited increased odds of inpatient complications, longer LOS, and greater admission costs after THA compared with non-transplant patients. 相似文献8.
P. Maxwell Courtney Nicholas B. Frisch Daniel D. Bohl Craig J. Della Valle 《The Journal of arthroplasty》2018,33(1):1-5
Background
Recent healthcare reform efforts have focused on improving the quality of total joint replacement care while reducing overall costs. The purpose of this study is to determine if higher volume centers have lower costs and better outcomes than lower volume hospitals.Methods
We queried the Centers for Medicare and Medicaid Services (CMS) Inpatient Charge Data and identified 2702 hospitals that performed a total of 458,259 primary arthroplasty procedures in 2014. Centers were defined as low (performing <100 total joint arthroplasty [TJA] per year) or high volume and mean total hospital-specific charges and inpatient payments were obtained. Patient satisfaction scores as well 30-day risk-adjusted complication and readmission scores were obtained from the multiyear CMS Hospital Compare database.Results
Of all the hospitals, 1263 (47%) hospitals were classified as low volume and performed 60,895 (12%) TJA cases. Higher volume hospitals had lower mean total hospital-specific charges ($56,323 vs $60,950, P < .001) and mean Medicare inpatient payments ($12,131 vs $13,289, P < .001). Higher volume facilities had a lower complication score (2.96 vs 3.16, P = .015), and a better CMS hospital star rating (3.14 vs 2.89, P < .001). When controlling for hospital geographic and demographic factors, lower volume hospitals are more likely to be in the upper quartile of inpatient Medicare costs (odds ratio 2.127, 95% confidence interval 1.726-2.621, P < .001).Conclusion
Hospitals that perform <100 TJA cases per year may benefit from adopting the practices of higher volume centers in order to improve quality and reduce costs. 相似文献9.
Gannon L. Curtis Mhamad Faour Jaiben George Alison K. Klika Wael K. Barsoum Carlos A. Higuera 《The Journal of arthroplasty》2018,33(6):1868-1871
Background
Studies have suggested that forced-air warmers (FAWs) increase contamination of the surgical site. In response, FAWs with high efficiency particulate air filters (FAW-HEPA) were introduced. This study compared infection rates following primary total joint arthroplasty (TJA) using FAW and FAW-HEPA.Methods
Primary TJA patients at a single healthcare system were retrospectively reviewed. A total of 5405 THA (n = 2419) and TKA (n = 2986) consecutive cases in 2013 and 2015 were identified. Patients in 2013 (n = 2792) had procedures using FAW, while FAW-HEPA was used in 2015 (n = 2613). The primary outcome was overall infection rate within 90-days. Sub-categorization of infections as periprosthetic joint infection (PJI) or surgical site infection (SSI) was also conducted. PJI was defined as reoperation with arthrotomy or meeting Musculoskeletal Infection Society (MSIS) criteria. SSI was defined as wound complications requiring antibiotics or irrigation/debridement.Results
The FAW and FAW-HEPA groups had similar rates of overall infection (1.65% [n = 46] vs 1.61% [n = 42], P > .99), SSI (1.18% [n = 33] vs 0.84% [n = 22], P = .27), and PJI (0.47% [n = 13] vs 0.77% [n = 20], P = .22). Regression models did not show FAW to be an independent risk factor for increased overall infection (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.65-1.57, P = .97), SSI (OR 1.47, 95% CI 0.83-2.58, P = .18), or PJI (OR 0.53, 95% CI 0.25-1.13, P = .09).Conclusion
FAW were not correlated with a higher risk of overall infection, SSI, or PJI during TJA when compared to FAW-HEPA devices. 相似文献10.
Background
Limited data describe risks and perioperative resource needs of total joint arthroplasty (TJA) in dialysis-dependent patients.Methods
Retrospective multiple cohort analysis of dialysis-dependent American College of Surgeons National Surgical Quality Improvement Program patients undergoing primary elective total hip and knee arthroplasty compared to non–dialysis-dependent controls from 2005 to 2015. Relative risks (RRs) of 30-day adverse events were determined by multivariate regression adjusting for baseline differences.Results
Six hundred forty-five (0.2%) dialysis-dependent patients of 342,730 TJA patients were dialysis-dependent and more likely to be dependent, under weight, anemic, hypoalbuminemic, and have cardiopulmonary disease. In total hip arthroplasty patients, dialysis was associated with greater risk of any adverse event (RR = 1.1, P < .001), mortality (RR = 2.8, P = .012), intensive care unit (ICU) care (RR = 9.8, P < .001), discharge to facility (RR = 1.3, P < .001), and longer admission (1.5×, P < .001). In total knee arthroplasty patients, dialysis conferred greater risk of any adverse event (RR = 1.1, P < .001), ICU care (RR = 6.0, P < .001), stroke (RR = 7.6, P < .001), cardiac arrest (RR = 4.8, P = .014), discharge to facility (RR = 1.5, P < .001), readmission (RR = 1.8, P = .002), and longer admission (1.3×, P < .001).Conclusion
Dialysis-dependence is an independent risk factor for 30-day adverse events, ICU care, longer admission, and rehabilitation needs in TJA patients. Thirty days is not sufficient to detect infectious complications among these patients. These findings inform shared decision-making, perioperative resource planning, and risk adjustment under alternative reimbursement models. 相似文献11.
Alexander S. McLawhorn Ashley E. Levack Yuo-yu Lee Yile Ge Huong Do Emily R. Dodwell 《The Journal of arthroplasty》2018,33(7):2062-2069.e4
Background
The purpose of this study was to compare risks for revision and short-term complications after total joint arthroplasty (TJA) in matched cohorts of morbidly obese patients, receiving and not receiving prior bariatric surgery.Methods
Patients undergoing elective TJA between 1997 and 2011 were identified in a New York Statewide database, analyzing total knee arthroplasty (TKA) and total hip arthroplasty (THA) separately. Propensity scores were used to match morbidly obese patients receiving and not receiving bariatric surgery prior to TJA. Cox proportional hazard modeling assessed revision risk. Logistic regression evaluated odds for complications.Results
For TKA, 2636 bariatric surgery patients were matched to 2636 morbidly obese patients. For THA, 792 bariatric surgery patients were matched to 792 morbidly obese patients. Matching balanced all covariates. Bariatric surgery reduced co-morbidities prior to TJA (TKA P < .0001; THA P < .005). Risks for in-hospital complications were lower for THA and TKA patients receiving prior bariatric surgery (odds ratio [OR] 0.25, P < .001; and OR = 0.69, P = .021, respectively). Risks for 90-day complications were lower for TKA (OR 0.61, P = .002). Revision risks were not different for either THA (P = .634) or TKA (P = .431), nor was THA dislocation risk (P = 1.000).Conclusion
After accounting for relevant selection biases, bariatric surgery prior to TJA was associated with reduced co-morbidity burden at the time of TJA and with reduced post-TJA complications. However, bariatric surgery did not reduce the risk for revision surgery for either TKA or THA. 相似文献12.
Randomized,multicenter trial comparing sternotomy closure with rigid plate fixation to wire cerclage
Keith B. Allen Vinod H. Thourani Yoshifumi Naka Kendra J. Grubb John Grehan Nirav Patel T. Sloane Guy Kevin Landolfo Marc Gerdisch Mark Bonnell David J. Cohen 《The Journal of thoracic and cardiovascular surgery》2017,153(4):888-896.e1
Objective
To evaluate sternal healing, complications, and costs after sternotomy closure with rigid plate fixation or wire cerclage.Methods
This prospective, single-blinded, multicenter trial randomized 236 patients at 12 US centers at the time of sternal closure to either rigid plate fixation (n = 116) or wire cerclage (n = 120). The primary endpoint, sternal healing at 6 months, was evaluated by a core laboratory using computed tomography and a 6-point scale (greater scores represent greater healing). Secondary endpoints included sternal complications and costs from the time of sternal closure through 6 months.Results
Rigid plate fixation resulted in better sternal healing scores at 3 (2.6 ± 1.1 vs 1.8 ± 1.0; P < .0001) and 6 months (3.8 ± 1.0 vs 3.3 ± 1.1; P = .0007) and greater sternal union rates at 3 (41% [42/103] vs 16% [16/102]; P < .0001) and 6 months (80% [81/101] vs 67% [67/100]; P = .03) compared with wire cerclage. There were fewer sternal complications through 6 months with rigid plate fixation (0% [0/116] vs 5% [6/120]; P = .03) and a trend towards fewer sternal wound infections (0% [0/116] vs 4.2% [5/120]; P = .06) compared with wire cerclage. Although rigid plate fixation was associated with a trend toward greater index hospitalization costs ($23,437 vs $20,574; P = .11), 6-month follow-up costs tended to be lower ($9002 vs $13,511; P = .14). As a result, total costs from randomization through 6 months were similar between groups ($32,439 vs $34,085; P = .61).Conclusions
Sternotomy closure with rigid plate fixation resulted in significantly better sternal healing, fewer sternal complications, and no additional cost compared with wire cerclage at 6 months after surgery. 相似文献13.
Rami O. Tadros Melissa L. Tardiff Peter L. Faries Michael Stoner Chien Yi M. Png David Kaplan Ageliki G. Vouyouka Michael L. Marin 《Journal of vascular surgery》2017,65(3):819-825
Objective
We have shown that vascular surgeon- hospitalist co management resulted in improved in-hospital mortality rates. We now aim to assess the impact of the hospitalist co management service (HCS) on healthcare cost.Methods
A total of 1558 patients were divided into three cohorts and compared: 516 in 2012, 525 in 2013, and 517 in 2014. The HCS began in January 2013. Data were standardized for six vascular surgeons that were present 2012-2014. New attendings were excluded. Ten hospitalists participated. Case mix index (CMI), contribution margin, total hospital charges (THCs), length of stay (LOS), actual direct costs (ADCs), and actual variable indirect costs (AVICs) were compared. Analysis of variance with post-hoc tests, t-tests, and linear regressions were performed.Results
THC rose by a mean difference of $14,578.31 between 2012 and 2014 (P < .001) with a significant difference found between all groups during the study period (P = .0004). ADC increased more than AVIC; however, both significantly increased over time (P = .0002 and P = .014, respectively). A mean $3326.63 increase in ADC was observed from 2012 to 2014 (P < .0001). AVIC only increased by an average $392.86 during the study period (P = .01). This increased cost was observed in the context of a higher CMI and longer LOS. CMI increased from 2.25 in 2012 to 2.53 in 2014 (P = .006). LOS increased by a mean 1.02 days between 2012 and 2014 (P = .016), and significantly during the study period overall (P = .018). After adjusting for CMI, LOS increases by only 0.61 days between 2012 and 2014 (P = .07). In a final regression model, THC is independently predicted by comanagement, CMI, and LOS. After adjusting for CMI and LOS, the increase in THC because of comanagement (2012 vs 2014) accounts for only $4073.08 of the total increase (P < .001). During this time, 30-day readmission rates decreased by ～7% (P = .005), while related 30-day readmission rates decreased by ～2% (P = .32). Physician contribution margin remained unchanged over the 3-year period (P = .76). The most prevalent diagnosis-related group was consistent across all years. Variation in the principal diagnosis code was observed with the prevalence of circulatory disorders because of type II diabetes replacing atherosclerosis with gangrene as the most prevalent diagnosis in 2013 and 2014 compared with 2012.Conclusions
In-hospital cost is significantly higher since the start of the HCS. This surge may relate to increased CMI, LOS, and improved coding. This increase in cost may be justified as we have observed sustained reduction in in-hospital mortality and slightly improved readmission rates. 相似文献14.
Jessica L.H. Phillips Alexander J. Rondon Zylyftar Gorica Yale A. Fillingham Matthew S. Austin P. Maxwell Courtney 《The Journal of arthroplasty》2018,33(12):3607-3611
Background
Due to concerns about higher complication rates, surgeons debate whether to perform simultaneous bilateral total joint arthroplasty (BTJA), particularly in the higher-risk Medicare population. Advances in pain management and rehabilitation protocols have called into question older studies that found an overall cost benefit for simultaneous procedures. The purpose of this study was to compare 90-day episode-of-care costs between staged and simultaneous BTJA among Medicare beneficiaries.Methods
We retrospectively reviewed a consecutive series of 319 simultaneous primary TJAs and 168 staged TJAs (336 procedures) at our institution between 2015 and 2016. We recorded demographics, comorbidities, readmission rates, and 90-day episode-of-care costs based upon Centers for Medicare and Medicaid Services claims data. To control for confounding variables, we performed a multivariate regression analysis to identify independent risk factors for increased costs.Results
Simultaneous patients had decreased inpatient facility costs ($19,402 vs $23,025, P < .001), increased post-acute care costs ($13,203 vs $10,115, P < .001), and no difference in total episode-of-care costs ($35,666 vs $37,238, P = .541). Although there was no difference in readmissions (8% vs 9%, P = .961), simultaneous bilateral patients were more likely to experience a thromboembolic event (2% vs 0%, P = .003). When controlling for demographics, procedure, and comorbidities, a simultaneous surgery was not associated with an increase in episode-of-care costs (P = .544). Independent risk factors for increased episode-of-care costs following BTJA included age ($394 per year increase, P < .001), cardiac disease ($4877, P = .025), history of stroke ($14,295, P = .010), and liver disease ($12,515, P = .016).Conclusion
In the Medicare population, there is no difference in 90-day episode-of-care costs between simultaneous and staged BTJA. Surgeons should use caution in performing a simultaneous procedure on older patients or those with a history of stroke, cardiac, or liver disease. 相似文献15.
Ali H. Sobh Matthew P. Siljander Anthony J. Mells Denise M. Koueiter Drew D. Moore Mark S. Karadsheh 《The Journal of arthroplasty》2018,33(2):320-323
Background
Simultaneous vs staged bilateral total knee arthroplasty (BTKA) has long been debated. The primary objective of this study was to compare actual hospital costs and complication rates in patients undergoing simultaneous BTKA (simBTKA) and staged BTKA (staBTKA) at a single institution.Methods
A total joint arthroplasty database from a single hospital was used to identify all patients who underwent primary BTKA from 2013 to 2016 and divided into simultaneous and staged groups. StaBTKA patients were included if both procedures were performed within 1 year by the same surgeon. The combined total hospital cost of both procedures was used, and inpatient rehabilitation (IPR) costs were added for all patients discharged to IPR.Results
There were 225 simBTKA and 337 staBTKA patients. SimBTKA patients were younger (61 ± 8 vs 66 ± 8 years, P < .001), had lower body mass index (31.3 ± 5.9 vs 34.0 ± 7.2, P < .001), were more predominately male (48% vs 38%, P = .029), and more likely to require IPR as compared with staBTKA patients. There was no difference in total hospital cost for simBTKA as compared with staBTKA ($24,596 ± $5652 vs $24,915 ± $5756, P = .586). Complications were more prevalent in the simBTKA group, including venous thromboembolism (5.4% vs 1.4%, P = .006) and blood transfusions (15.8% vs 6.2%, P < .001).Conclusion
There were higher complication rates with no significant cost savings in actual hospital costs associated with simBTKA, when accounting for the cost of IPR, as compared with staBTKA. The total cost analysis of simBTKA vs staBTKA, using actual cost data, merits further evaluation. 相似文献16.
Matthew R. Boylan James D. Slover Joan Kelly Lorraine H. Hutzler Joseph A. Bosco 《The Journal of arthroplasty》2019,34(3):408-411
Background
Private hospital rooms have a number of potential advantages compared to shared rooms, including reduced noise and increased control over the hospital environment. However, the association of room type with patient experience metrics in total joint arthroplasty (TJA) patients is currently unclear.Methods
For private versus shared rooms, we compared our institutional Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in patients who underwent primary TJA over a 2-year period. Regression model odds ratios (ORs) were adjusted for surgeon, date of surgery, and length of stay.Results
Patients in private rooms were more likely to report a top-box score for overall hospital rating (85.6% vs 79.4%, OR = 1.53, P = .011), hospital recommendation (89.3% vs 83.0%, OR = 1.78, P = .002), call button help (76.0% vs 68.7%, OR = 1.40, P = .028), and quietness (70.4% vs 59.0%, OR = 1.78, P < .001). There were no significant differences on surgeon metrics including listening (P = .225), explanations (P = .066), or treatment with courtesy and respect (P = .396).Conclusion
For patients undergoing TJA, private hospital rooms were associated with superior performance on patient experience metrics. This association appears specific for global and hospital-related metrics, with little impact on surgeon evaluations. With the utilization of HCAHPS data in value-based initiatives, placement of TJA patients in private rooms may lead to increased reimbursement and higher hospital rankings.Level of Evidence
Level III, retrospective cohort. 相似文献17.
Molly A. Day Christopher A. Anthony Nicholas A. Bedard Natalie A. Glass Charles R. Clark John J. Callaghan Nicolas O. Noiseux 《The Journal of arthroplasty》2018,33(1):19-24
Background
Automated mobile phone messaging has not been reported in total joint arthroplasty (TJA). Our purpose was to compare Press Ganey (PG) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores between TJA patients who did and did not receive perioperative automated mobile phone messages.Methods
Patients were prospectively enrolled and received messages for 1 week prior until 2 weeks after TJA. Message content included reminders, activity, and pain control. Patients answered select PG/HCAHPS and questions regarding their experience with the automated communication platform. Average PG/HCAHPS scores were compared to historical TJA patients in the 3-year window prior (control group) with significance P < .05.Results
Thirty-seven consecutive patients were approached and 92% (n = 34) were enrolled. The experimental group was 47% male, with 80% patients between 51 and 75 years. The experimental (n = 30) and control groups (n = 26) were similar. Patients receiving messages were more likely to have a good understanding of health responsibilities (P = .024) and feel that the care team demonstrated shared decision-making (P = .024). Of patients enrolled, 87% felt messages helped them be more prepared for surgery, 100% felt messages kept them better informed, and 97% would participate again.Conclusion
TJA patients who received perioperative communication via automated mobile phone messaging had improved patient satisfaction scores postoperatively. Patients perceived this form of communication was useful and kept them better informed. Automated mobile phone messaging can be an easily integrated, helpful adjunct to surgeons, healthcare systems, and case managers to more effectively communicate with patients undergoing TJA in this era of value-based care. 相似文献18.
Feng-Chih Kuo Chee-Jen Chang Kerri L. Bell Mel S. Lee Jun-Wen Wang 《The Journal of arthroplasty》2018,33(10):3147-3152.e1
Background
Controversy remains regarding the outcomes after total joint arthroplasty (TJA) among patients with or without liver transplantation (LT). This study aimed at investigating the prevalence of TJA in patients after LT and comparing the morbidity and mortality with the non-LT group.Methods
We conducted a nationwide, population-based study, with data extracted from a universal health insurance database, based on the International Classification of Disease, Ninth Revision, Clinical Modification. Patients who underwent TJAs between January 2001 and December 2014 were included. Patients who had bilateral TJAs or a TJA before LT were excluded. A total of 43 patients with LT and 350,337 patients without LT were included. The analysis was implemented using data from all patients and those matched by 1-to-10 propensity score matching. Multivariable logistic regression was used to control confounding variables.Results
The prevalence of patients undergoing TJA after LT was 1.3% (43/3276). After propensity score matching, patients with LT were not associated with 30-day complications (adjusted odds ratio [aOR], 0.98; 95% confidence interval [CI], 0.93-1.03; P = .35), 30-day readmission rates (aOR, 0.93; 95% CI, 0.92-1.08; P = .87), 90-day complication rates (aOR, 0.95; 95% CI, 0.88-1.02; P = .16), 1-year infection rates (aOR, 1.04; 95% CI, 0.96-1.12; P = .35), reoperation rates (aOR, 1.06; 95% CI, 0.92-1.23; P = .41), or mortality (aOR, 0.91; 95% CI, 0.80-1.04; P = .18).Conclusion
The morbidity and mortality seem to be comparable whether TJA is performed in patients with or without LT. Methods for risk assessment would be feasible in liver transplant recipients. 相似文献19.
Ourania Preventza Joseph S. Coselli Andrea Garcia Shahab Akvan Sarang Kashyap Katherine H. Simpson Matt D. Price Kim I. de la Cruz Konstantinos Spiliotopoulos Lorraine D. Cornwell Faisal G. Bakaeen Shuab Omer Denton A. Cooley 《The Journal of thoracic and cardiovascular surgery》2017,153(3):511-518
Objective
Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery.Methods
During 2006-2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not.Results
Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-total arch (hemiarch) replacement patients. Ventilator support >48 hours (P < .0001) was associated with longer LOS. Elective aortic valve?sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028).Conclusions
In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve–sparing root replacement, when feasible, may also reduce LOS. 相似文献20.
Faisal G. Bakaeen A. Laurie Shroyer Marco A. Zenati Vinay Badhwar Vinod H. Thourani James S. Gammie Rakesh M. Suri Joseph F. Sabik A. Marc Gillinov Danny Chu Shuab Omer Mary T. Hawn G. Hossein Almassi Lorraine D. Cornwell Frederick L. Grover Todd K. Rosengart Laura Graham 《The Journal of thoracic and cardiovascular surgery》2018,155(1):105-117.e5