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1.
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2.
John M. Yanik Nicholas A. Bedard Jessica M. Hanley Jesse E. Otero John J. Callaghan John L. Marsh 《The Journal of arthroplasty》2018,33(10):3138-3142
Background
Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting.Methods
In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively.Results
After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07).Conclusion
In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty. 相似文献3.
Mitsuru Yagi Nobuyuki Fujita Eijiro Okada Osahiko Tsuji Narihito Nagoshi Takashi Tsuji Masaya Nakamura Morio Matsumoto Kota Watanabe 《Journal of orthopaedic science》2018,23(4):653-657
Background
Cost-utility analysis of surgery for degenerative lumber spondylolisthesis (DS) is essential for healthcare providers and patients to select appropriate treatment. The purpose of this study was to review the cost-utility of decompression alone versus decompression with fusion for DS.Methods
A retrospective review of 99 consecutive patients who were treated for Meyerding grade 1 DS at two representative spine centers was performed. Patients with significant spinal instability were treated by decompression with fusion (F group, 40 patients); all others were treated by decompression surgery alone (D group, 59 patients). All patients were followed for three years. Demographic and radiographic data, health-related quality of life (HRQoL), and the direct cost for surgery were analyzed, and the incremental cost-effectiveness ratio (ICER) was determined using cost/quality-adjusted life years (QALY).Results
There were no differences between the groups in baseline demographics (D vs. F: age 68 ± 9 vs. 66 ± 7 years; 37% vs. 40% female) or HRQoL (ODI: D, 41 ± 16 vs. F, 46 ± 13%). The F group had a higher initial-surgery cost ($18,992 ± 2932) but lower reoperation frequency (7%) than the D group ($7660 ± 2182 and 12%, respectively). The three-year total direct cost was higher for F than for D ($19,222 ± 3332 vs. $9668 ± 6,168, p = .01). ICER was higher for F at one year ($136,408 ± 187,911 vs. $237,844 ± 212,049, p < .01), but was comparable for F and D at three years (D, $41,923 ± 44,503 vs. F, $51,313 ± 32,849, p = .17).Conclusion
At the three-year follow-up, the two methods had comparable cost-utility. Both methods were cost-effective (defined as an ICER within three times the per-capita gross domestic product). 相似文献4.
Young Erben Raymond A. Jean Clinton D. Protack Alex S. Chiu Shirley Liu Brandon J. Sumpio Samuel M. Miller Bauer E. Sumpio 《Journal of vascular surgery》2018,67(6):1805-1812
Objective
Chronic mesenteric ischemia (CMI) continues to be a devastating diagnosis. There is a national trend toward increased use of endovascular procedures with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed CMI patients' length of hospitalization and health care cost.Methods
We identified all patients admitted for CMI from the National Inpatient Sample (NIS) from 2000 to 2014. Our primary end points included length of hospital stay (LOS) and cost of hospitalization (COH). Our secondary end points included mortality assessment of the CMI hospitalization.Results
There were 15,475 patients admitted for CMI. The mean age of patients was 71 years, and 4022 (26.0%) were male. There were 10,920 (70.6%) patients treated endovascularly (ENDO) and 4555 (29.4%) patients treated in an open fashion (OPEN). Although a higher proportion of patients in the ENDO (43.3%) group vs OPEN (33.1%) had a Charlson Comorbidity Index score of ≥2 (P < .0001), they had a lower mortality rate (2.4% vs 8.7%; P < .0001), lower mean LOS (6.3 vs 14.0 days; P < .0001), and lower COH ($21,686 vs $42,974; P < .0001). After adjusting for clinical and hospital factors, OPEN continued to demonstrate higher mortality than ENDO (odds ratio, 7.2; 95% confidence interval, 4.9-10.6; P < .0001), longer LOS (mean, +9.7 days; P < .0001), and higher COH (mean, +$25,834; P < .0001).Conclusions
The rate of ENDO continues to rise nationally in the treatment of CMI patients. After adjusting for clinical and hospital factors, patients in the ENDO group tend to have lower in-hospital mortality of 2.4% and lower LOS by 10 days, and they incur a cost saving of >$25,000 compared with patients in the OPEN group. ENDO should be considered first line of therapy for patients with CMI. 相似文献5.
Nipun Sodhi Nicolas S. Piuzzi Anton Khlopas Jared M. Newman Thomas J. Kryzak Kim L. Stearns Michael A. Mont 《The Journal of arthroplasty》2018,33(2):340-344
Background
Relative value units (RVUs) are used to evaluate the effort required for providing a service to patients in order to determine compensation. Thus, more complicated cases, like revision arthroplasty cases, should yield a greater compensation. However, there are limited data comparing RVUs to the time required to complete the service. Therefore, the purpose of this study is to compare the (1) mean RVUs, (2) mean operative times, and (3) mean RVU/minute between primary and revision total hip arthroplasty (THA) and (4) perform an individualized idealized surgeon annual cost difference analysis.Methods
A total of 103,702 patients who underwent primary (current procedural terminology code 27130) and 7273 patients who underwent revision THA (current procedural terminology code 27134) were identified using the National Surgical Quality Improvement Program database. Mean RVUs, operative times (minutes), and RVU/minute were calculated and compared using Student t-test. Dollar amount per minute, per case, per day, and year was calculated to find an individualized idealized surgeon annual cost difference.Results
The mean RVU was 21.24 ± 0.53 (range, 20.72-21.79) for primary and 30.27 ± 0.03 (range, 30.13-30.28) for revision THA (P < .001). The mean operative time for primary THA was 94 ± 38 minutes (range, 30-480 minutes) and 152 ± 75 minutes (range, 30-475 minutes) for revision THA (P < .001). The mean RVU/minute was 0.260 ± 0.10 (range, 0.04-0.73) for primary and 0.249 ± 0.12 (range, 0.06-1.0) for revision cases (P < .001). The dollar amounts calculated for primary vs revision THA were as follows: per minute ($9.33 vs $8.93), per case ($877.12 vs $1358.32), per day ($6139.84 vs $5433.26), and a projected $113,052.28 annual cost difference for an individual surgeon.Conclusion
Maximizing the RVU/minute provides the greatest “hourly rate.” The RVU/minute for primary (0.260) being significantly greater than revision THA (0.249) and an annualized $113,052.28 cost difference reveal that although revision THAs are more complex cases requiring longer operative time, greater technical skill, and aftercare, compensation per time is not greater. 相似文献6.
Caitlin W. Hicks Husain N. Alshaikh Devin Zarkowsky Ian C. Bostock Besma Nejim Mahmoud B. Malas 《Journal of vascular surgery》2018,67(4):1091-1101.e4
Background
A large proportion of endovascular aortic aneurysm repair (EVAR) patients are routinely admitted to the intensive care unit (ICU) for postoperative observation. In this study, we aimed to describe the factors associated with ICU admission after EVAR and to compare the outcomes and costs associated with ICU vs non-ICU observation.Methods
All patients undergoing elective infrarenal EVAR in the Premier database (2009-2015) were included. Patients were stratified as ICU vs non-ICU admission according to location on postoperative day 0. Both patient-level (sociodemographics, comorbidities) and hospital-level (teaching status, hospital size, geographic location) factors were analyzed using univariate and multivariable logistic regression to determine factors associated with ICU vs non-ICU admission. Overall outcomes and hospital costs were compared between groups.Results
Overall, 8359 patients underwent elective EVAR during the study period, including 4791 (57.3%) ICU and 3568 (42.7%) non-ICU admissions. Patients admitted to ICU were more frequently nonwhite and had more comorbidities, including congestive heart failure, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, and hypertension, than non-ICU patients (all, P < .03). ICU admissions were more common in small (<300 beds), urban, and nonteaching hospitals and varied greatly depending on surgeon specialty and geographic region (P < .001). A pattern emerged when admission location was clustered by hospital; ICU patients were treated at hospitals where 96.7% (interquartile range, 84.5%-98.9%) of patients were admitted to ICU after EVAR, whereas non-ICU patients were treated at hospitals where only 7.5% (interquartile range, 4.9%-25.8%) were admitted to ICU after EVAR. A multivariable logistic regression model accounting for patient-, operative-, and hospital-level differences had a significantly lower area under the curve for predicting ICU admission after EVAR than a model accounting only for hospital factors (area under the curve, 0.76 vs 0.95; P < .001). The overall rate of adverse events was higher for ICU vs non-ICU patients (16.3% vs 13.7%; P < .001). Failure to rescue (2.9% vs 3.9%; P = .42) and in-hospital mortality (0.4% vs 0.4%; P = .81) were similar between groups. After adjusting for patient and hospital factors as well as for postoperative adverse events, ICU admission after EVAR cost $1475 (95% confidence interval, $768-2183) more than non-ICU admission (P < .001).Conclusions
Among patients undergoing elective EVAR, postoperative ICU admission is more closely associated with hospital practice patterns than with individual patient risk. Routine ICU admission after EVAR adds significant cost without reducing failure to rescue or in-hospital mortality. 相似文献7.
Joseph F. Konopka Robert L. Buly Bryan T. Kelly Edwin P. Su Alexander S. McLawhorn 《The Journal of arthroplasty》2018,33(6):1806-1812
Background
A significant number of patients who undergo hip arthroscopy will subsequently undergo total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA), although limited evidence exists regarding effects of prior hip arthroscopy on the outcomes of these procedures.Methods
Of 5091 patients who underwent hip arthroscopy, we identified 69 patients who underwent subsequent THA (46) or HRA (23). Patients were matched to patients with no history of hip arthroscopy. Preoperative and 2-year postoperative Hip disability and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12, Lower Extremity Activity Scale score, and satisfaction surveys were compared.Results
Patients who underwent THA with history of arthroscopy had lower postoperative Hip disability and Osteoarthritis Outcome Score Pain (82 ± 16 vs 93 ± 9, P = .003), Stiffness (85 ± 16 vs 93 ± 15, P = .01), Sports and Recreation (71 ± 22 vs 88 ± 18, P = .003), Quality-of-Life (65 ± 22 vs 86 ± 11, P < .0001), WOMAC Pain (86 ± 16 vs 93 ± 15, P = .03), WOMAC Stiffness (80 ± 21 vs 88 ± 17, P = .05), and Short Form-12 Physical Component Scores (48 ± 11 vs 54 ± 6, P = .008). They were less likely to be “very satisfied” after arthroplasty (71% vs 89%, P = .0008).Conclusion
Hip arthroscopy before hip arthroplasty is associated with slightly lower results in several patient-reported outcomes. These results are relevant when assessing patients for hip arthroscopy and when counseling prospective arthroplasty patients with history of arthroscopy. 相似文献8.
Jason B. O&#x;Neal Andrew A. Freiberg Marc D. Yelle Yandong Jiang Chengwei Zhang Yin Gu Xiangyi Kong Wenling Jian Wesley T. O&#x;Neal Jingping Wang 《The Journal of arthroplasty》2017,32(10):3029-3033
Background
The efficacy of intravenous (IV) acetaminophen compared with its oral formulation for postoperative analgesia is unknown. We hypothesized that the addition of acetaminophen to a multimodal analgesia regimen would provide improved pain management in patients after total knee arthroplasty (TKA) and that the effect of acetaminophen would be variable based on the route of delivery.Methods
The study was a single-center, randomized, double-blinded, placebo-controlled clinical trial on the efficacy of IV vs oral acetaminophen in patients undergoing unilateral TKA. One hundred seventy-four subjects were randomized to one of the 3 groups: IV acetaminophen group (IV group, n = 57) received 1 g IV acetaminophen and oral placebo before postanesthesia care unit (PACU) admission; oral acetaminophen group (PO group, n = 58) received 1 g oral acetaminophen and volume-matched IV normal saline; placebo group (Placebo group, n = 59) received oral placebo and volume-matched IV normal saline. Pain scores were obtained every 15 minutes during PACU stay. Average pain scores, maximum pain score, and pain scores before physical therapy were compared among the 3 groups. Secondary outcomes included total opiate consumption, time to PACU discharge, time to rescue analgesia, and time to breakthrough pain.Results
The average PACU pain score was similar in the IV group (0.56 ± 0.99 [mean ± standard deviation]) compared with the PO group (0.67 ± 1.20; P = .84) and Placebo group (0.58 ± 0.99; P = .71). Total opiate consumption at 6 hours (0.47 mg hydromorphone equivalents ± 0.56 vs 0.54 ± 0.53 vs 0.54 ± 0.61; P = .69) and at 24 hours (1.25 ± 1.30 vs 1.49 ± 1.34 vs 1.36 ± 1.31; P = .46) were also similar between the IV, PO, and Placebo groups. No significant differences were found between all groups for any other outcome.Conclusion
Neither IV nor oral acetaminophen provides additional analgesia in the immediate postoperative period when administered as an adjunct to multimodal analgesia in patients undergoing TKA in the setting of a spinal anesthetic. 相似文献9.
Bina Eftekharsadat Peyman Roomizadeh Shervin Torabi Fariba Heshmati-Afshar Fatemeh Jahanjoo Arash Babaei-Ghazani 《Journal of hand therapy》2018,31(4):437-442
Study Design
Randomized controlled trial.Introduction
Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper extremity. To date, no previous study has evaluated the efficacy of topical Lavendula stoechas (Lavender) oil in CTS patients.Purpose of the Study
To investigate the effectiveness of topical Lavender essential oil in pain intensity, isometric pinch strength, electrophysiological features, and functional status of patients with mild to moderate CTS.Methods
Forty eight patients with mild to moderate CTS were enrolled in this randomized placebo-controlled trial. Group A was treated with night wrist orthotic and topical lavender oil ointment. Group B was treated with night wrist orthotic and a placebo ointment. Patients were evaluated at baseline, and after 40 days of intervention with Boston CTS questionnaire (BCTQ), visual analog scale (VAS) for pain, pinch grip strength, power grip, median compound motor action potential latency, and median sensory nerve action potential latency.Results
At the end of the study period, both groups improved significantly in terms of BCTQ, VAS, isometric pinch powers, and electrodiagnosis study parameters. However, group A showed significantly greater improvements in BCTQ (mean difference, 0.39 ± 0.31 vs 0.6 ± 0.35; P = .03), VAS (3.37 ± 1.86 vs 1.33 ± 2.07; P = .001), and pinch grip strength (0.73 ± 0.63 vs 0.27 ± 0.54; P = .01) than group B. No significant differences in power grip, median compound motor action potential latency, and median sensory nerve action potential latency were seen between the 2 groups.Conclusion
This study was the first trial of topical lavender oil used in patients with CTS. Wrist orthotic combined with topical lavender oil was more effective than orthotic and placebo in treatment of mild to moderate CTS.Level of Evidence
1b. 相似文献10.
Mauro Podda Nicola Cillara Salomone Di Saverio Antonio Lai Francesco Feroci Gianluigi Luridiana Ferdinando Agresta Nereo Vettoretto 《The surgeon》2017,15(5):303-314
Background
Acute appendicitis is the most common surgical diagnosis in young patients, with lifetime prevalence of about 7%. Debate remains on whether uncomplicated AA should be operated or not. Aim of this meta-analysis of randomized controlled trials was to assess current evidence on antibiotic treatment for uncomplicated AA compared to standard surgical treatment.Methods
Systematic literature search was performed using PubMed, EMBASE, Medline, Google Scholar and Cochrane Central Register of Controlled Trials databases for randomized controlled trials comparing antibiotic therapy (AT) and surgical therapy-appendectomy (ST) for uncomplicated AA. Trials were reviewed for primary outcome measures: treatment efficacy based on 1 year follow-up, recurrence at 1 year follow-up, complicated appendicitis with peritonitis identified at the time of surgical operation and post-intervention complications. Secondary outcomes were length of hospital stay and period of sick leave.Results
Five RCTs comparing AT and ST qualified for inclusion in meta-analysis, with 1.351 patients included: 632 in AT group and 719 in ST group. Higher rate of treatment efficacy based on 1 year follow-up was found in ST group (98.3% vs 75.9%, P < 0.0001), recurrence at 1 year was reported in 22.5% of patients treated with antibiotics. Rate of complicated appendicitis with peritonitis identified at time of surgical operation was higher in AT group (19.9% vs 8.5%, P = 0.02). No statistically significant differences were found when comparing AT and ST groups for the outcomes of overall post-intervention complications (4.3% vs 10.9%, P = 0.32), post-intervention complications based on the number of patients who underwent appendectomy (15.8% vs 10.9%, P = 0.35), length of hospital stay (3.24 ± 0.40 vs 2.88 ± 0.39, P = 0.13) and period of sick leave (8.91 ± 1.28 vs 10.27 ± 0.24, P = 0.06).Conclusions
With significantly higher efficacy and low complication rates, appendectomy remains the most effective treatment for patients with uncomplicated AA. The subgroups of patients with uncomplicated AA where antibiotics can be more effective, should be accurately identified. 相似文献11.
Objective
Besides severe organ shortage, hepatitis C virus (HCV) infection is an important obstacle for kidney transplantation because of long waiting times on deceased kidney donor waiting lists. We aimed to evaluate calling number of candidates according to HCV serology.Method
A total of 404 adults on the deceased donor waiting list invited for cadaveric transplantation was evaluated. Demographic data, waiting time, calling number for transplantation, and viral serology were obtained during the 6-year period.Results
Mean waiting duration and calling number of all patients were 42.7 ± 34 months and 1.56 ± 4.37 times, respectively. Twenty-six candidates had chronic HCV infection and 12 of 26 were HCV RNA–positive. Mean waiting duration and calling number in anti-HCV–positive candidates were significantly higher compared with anti-HCV–negative candidates (85.3 ± 38.8 vs 39.8 ± 31.6 months, and 10.8 ± 10.3 vs 0.92 ± 2.6 times, respectively; P < .001). Mean waiting duration and total calling number in HCV-RNA–positive candidates were significantly higher than in HCV-RNA–negative ones (107.5 ± 7.5 vs 66.2 ± 44.8 months; P = .018; 15 ± 9.7 vs 7.3 ± 9.8 times, respectively; P = .026).Conclusions
Chronic HCV infection is an important issue leading to longer waiting time on the list. Our observation showed that waiting durations of anti-HCV–positive candidates were longer than that of negative patients, although they had more frequent opportunity for transplantation. 相似文献12.
Clayton R. Perry Adam M. Fahs Michael D. Kurdziel Denise M. Koueiter Randy J. Fayne James J. Verner 《The Journal of arthroplasty》2018,33(6):1770-1774
Background
Modern joint arthroplasty protocols place an emphasis on minimizing patient-reported postoperative pain while minimizing opioid consumption. The use of multimodal pain management protocols has been reported to improve patient outcomes and satisfaction after total hip arthroplasty.Methods
In a prospective, single-surgeon trial, 50 patients undergoing primary direct anterior approach total hip arthroplasty were randomized to receive a preoperative fascia iliaca compartment block (FICB) or an intraoperative surgeon-delivered psoas compartment block (PCB). Patient-reported pain was recorded in the postanesthesia care unit, recovery floor and 3 weeks postoperatively. Opioid use was recorded during the hospital stay.Results
Average visual analog scale pain scores in the postanesthesia care unit were 38.7 ± 8.7 vs 35.6 ± 8.3 (P = .502) for the preoperative FICB and intraoperative PCB groups, respectively. No significant difference was found between groups at the 3-week visit for postoperative pain (FICB: 2.9 ± 1.4; PCB: 3.2 ± 2.0; P = .970) and patient-reported pain satisfaction (FICB: 8.8 ± 2.2; PCB: 9.7 ± 0.6; P = .110).Conclusion
During the direct anterior approach for total hip arthroplasty, PCB is an effective and efficient regional anesthesia technique. It may be used to obtain satisfactory postoperative pain control and patient satisfaction while decreasing hospital resources. 相似文献13.
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14.
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15.
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16.
Tammam Obeid Husain Alshaikh Besma Nejim Isibor Arhuidese Satinderjit Locham Mahmoud Malas 《Journal of vascular surgery》2017,65(5):1398-1406.e1
Objective
Despite multiple landmark clinical trials, little data exists on real-world cost of carotid artery stenting (CAS) and carotid endarterectomy (CEA) to the United States healthcare system. We aim to study differences in actual hospitalization cost between patients who underwent CAS vs CEA in a nationally representative database.Methods
We studied hospital discharge and billing records of all patients, in the Premier Perspective Database, who underwent CEA or CAS between the third quarter of 2009 and the first quarter of 2015. Nearest-neighbor 1:1 propensity score matching was performed, to account for differences in patient and hospital characteristics as well as clinical comorbidities of patients who underwent both procedures, for both symptomatic and asymptomatic cohorts using 32 variables. Pearson χ2, Student t-test, and nonparametric K-sample equality-of-medians tests were used to analyze the data, as appropriate. The primary outcome was total in-hospital cost, including fixed (administrative, capital and utilities) and variable costs (labor and supply). Cost data were presented as medians, inflation-adjusted for 2015 U.S. dollar and rounded to the nearest dollar.Results
A total of 115,548 procedures were identified. The mean age was 71 and 69 years; 58% and 57% were male patients; and 81% and 77% were white among asymptomatic and symptomatic patients, respectively. After propensity score matching, 25,812 asymptomatic (12,906 CEA and 12,906 CAS) and 3864 symptomatic (1932 CEA and 1932 CAS) patients were included. Total hospitalization cost per CAS was 40% ($11,814 vs $8378; P < .001) and 37% ($19,426 vs $14,190; P < .001) higher than CEA among asymptomatic and symptomatic patients, respectively. Patients who underwent CAS incurred significantly higher total hospitalization cost despite stratifying by type of cost (fixed and variable), U.S. census regions and symptomatic status. Moreover, asymptomatic patients who underwent CAS performed by any surgical specialty incurred an average of $2717 to $4918 higher total hospitalization cost compared with patients who underwent CEA (all P < 001). Among symptomatic patients, those who underwent CAS performed by vascular, cardiac, and neurologic surgeons, incurred $2108 ($16,114 vs $14,006; P = .006), $7055 ($17,351 vs $10,296; P = .023) and $6479 ($27,290 vs $20,811; P = .002) higher total hospitalization cost compared with patients who underwent CEA, respectively.Conclusions
The total hospitalization cost incurred by patients who underwent CAS was significantly higher than for those who underwent CEA, despite matching cohort based on patient and hospital characteristics, and stratifying by symptomatic status, type of cost, hospital region, and surgeon specialty. Our findings could provide additional important information giving the ongoing controversy regarding the appropriate indication for CAS. 相似文献17.
Jelle P. van der List Harshvardhan Chawla Jordan C. Villa Andrew D. Pearle 《The Journal of arthroplasty》2017,32(3):761-766
Background
Medial unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) are both viable treatment options for medial osteoarthritis (OA). However, it remains unclear when to choose for which arthroplasty treatment. Goals of this study were therefore to (1) compare outcomes after both treatments and (2) assess which treatment has superior outcomes in different patient subgroups.Methods
In this retrospective cohort study, 166 patients received the RESTORIS MCK Medial UKA and 63 patients the Vanguard TKA and were radiographically matched on isolated medial OA. Western Ontario and McMaster Universities Arthritis Index scores were collected preoperatively and postoperatively (mean: 3.0 years, range: 2.0-5.0 years).Results
Preoperatively, no differences were observed, but medial UKA patients reported better functional outcomes than TKA (89.7 ± 13.6 vs 81.2 ± 18.0, P = .001) at follow-up.Better functional outcomes were noted after medial UKA in patients younger than age 70 years (89.5 ± 14.2 vs 78.6 ± 20.0, P = .001), with body mass index below 30 (90.3 ± 11.4 vs 83.6 ± 14.9, P = .005), with body mass index above 30 (88.3 ± 17.5 vs 78.8 ± 21.0, P = .034) and in females (90.6 ± 11.0 vs 78.1 ± 19.4, P = .001) when compared with TKA. No differences were found in males and older patients between both arthroplasties.Conclusion
Superior functional outcomes were noted after medial UKA over TKA in patients presenting with medial OA with these prostheses. Subgroup analyses suggest that medial UKA is the preferred treatment in younger patients and females while no differences were noted in older patients and males after medial UKA and TKA. This might help the orthopedic surgeon in individualizing arthroplasty treatment for patients with medial OA. 相似文献18.
J.G.Y. Luc K. Jackson J.G. Weinkauf D.H. Freed J. Nagendran 《Transplantation proceedings》2017,49(8):1885-1892
Background
Donation after circulatory death (DCD) has the potential to significantly alleviate the shortage of transplantable lungs. We report our initial experience with the use of portable ex vivo lung perfusion (EVLP) with the Organ Care System Lung device for evaluation of DCD lungs.Methods
We performed a retrospective review of the DCD lung transplantation (LTx) experience at a single institution through the use of a prospective database.Results
From 2011 to 2015, 208 LTx were performed at the University of Alberta, of which 11 were DCD LTx with 7 (64%) that underwent portable EVLP. DCD lungs preserved with portable EVLP had a significantly shorter cold ischemic time (161 ± 44 vs 234 ± 60 minutes, P = .045), lower grade of primary graft dysfunction at 72 hours after LTx (0.4 ± 0.5 vs 2.1 ± 0.7, P = .003), similar mechanical ventilation time (55 ± 44 vs 103 ± 97 hours, P = .281), and hospital length of stay (29 ± 11 vs 33 ± 10 days, P = .610). All patients were alive at 1-year follow-up after LTx with improved functional outcomes and acceptable quality of life compared with before LTx, although there were no intergroup differences.Conclusions
In our pilot cohort, portable EVLP was a feasible modality to increase confidence in the use of DCD lungs with validated objective evidence of lung function during EVLP that translates to acceptable clinical outcomes and quality of life after LTx. Further studies are needed to validate these initial findings in a larger cohort. 相似文献19.
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20.
Trevor R. Grace Joseph T. Patterson Jennifer Tangtiphaiboontana Justin D. Krogue Thomas P. Vail Derek T. Ward 《The Journal of arthroplasty》2018,33(6):1681-1685