Causes,risk factors,and costs associated with ninety-day readmissions following primary total hip arthroplasty for femoral neck fractures

IntroductionRisk factors associated with primary THA readmissions have not yet been thoroughly analyzed when stratified by underlying indication. Given that a majority of THAs are done electively in the context of osteoarthritis (OA), it remains to be explored whether or not THAs performed non-electively in the trauma setting have different readmission patterns. Therefore, the aims of this study were to identify: 1) causes of readmissions; 2) patient-related risk-factors for readmissions; and 3) costs associated with the reasons for readmissions.Materials and methodsPatients who sustained a femoral neck fracture and underwent primary THA from 2005 to 2014 were identified. Those subsequently readmitted within 90-days following the procedure comprised the study cohort whereas those not readmitted served as the comparison cohort. Primary outcomes included identifying causes of readmissions, identifying patient-related risk-factors associated with readmissions and determining healthcare expenditures associated with the different readmission etiologies. A regression analysis was used to calculate the odds (OR) for readmissions. A p-value less than 0.01 was considered to be statistically significant.ResultsThe regression model demonstrated the greatest patient-related risk factors included: electrolyte and fluid disorders (OR: 1.80, p < 0.0001), morbid obesity (OR: 1.60, p < 0.0001), pathologic weight loss (OR: 1.58, p < 0.0001), congestive heart failure (OR: 1.41, p < 0.0001), were the leading risk factors for readmissions. Pulmonary-related causes ($42,357.71) of readmission were the leading driver of costs of care.ConclusionOrthopaedic surgeons should identify and optimize pre-operative management of patient-related risk factors that increase readmissions following primary THA for femoral neck fractures. Additionally, pulmonary-related causes of readmission lead to the highest costs of care.Level of EvidenceIII.     

Radical prostatectomy for clinically localized, high risk prostate cancer: critical analysis of risk assessment methods

PURPOSE: Standardized criteria are lacking to define high risk, clinically localized prostate cancer before definitive treatment. Reliance on simple risk stratification schemes to define high risk cancers has led many physicians and patients toward therapeutic nihilism, inappropriately selecting androgen deprivation instead of definitive local therapy. Of patients undergoing radical prostatectomy we identified those at high risk based on 8 previously described definitions. We examined pathological characteristics and prostate specific antigen outcomes. MATERIALS AND METHODS: The study population included 4,708 men treated with radical prostatectomy alone between 1985 and 2004. Estimates of prostate specific antigen relapse for patients at high risk were generated with the Kaplan-Meier method. Cox proportional hazards regression was used to estimate the HR for recurrence in high risk vs nonhigh risk cohorts. RESULTS: Depending on the definition used patients at high risk composed 3% to 38% of the study population. The proportion of patients with extracapsular extension, seminal vesicle invasion and lymph node metastasis among men with high risk cancer was 35% to 71%, 10% to 33% and 7% to 23%, respectively. Of the high risk tumors 22% to 63% proved to be confined to the prostate pathologically. While patients at high risk had a 1.8 to 4.8-fold increased hazard of prostate specific antigen relapse, their 5-year relapse-free probability after radical prostatectomy alone was 49% (95% CI 39 to 58) to 80% (95% CI 77 to 83). Of patients at high risk who had relapse 25% across all definitions experienced relapse more than 2 years after surgery and in 26% to 39% prostate specific antigen doubling time at recurrence was 10 months or greater. CONCLUSIONS: Patients diagnosed with high risk cancer by currently available definitions do not have a uniformly poor prognosis after radical prostatectomy. Many cancers classified clinically as high risk are actually confined to the prostate pathologically. The risk of extraprostatic disease and prostate specific antigen relapse varies greatly depending on the definition used.     

Radical prostatectomy for low risk carcinoma of the prostate

Objectives  To review the role of radical prostatectomy in the management of patients with low risk carcinoma of the prostate. Methods  A summary of personal experience and pertinent literature is provided. In particular, information which permits conclusions on the efficacy and side effects of radical prostatectomy in this situation is considered. Results  For patients with low risk carcinoma of the prostate who choose to undergo treatment with curative intent, radical prostatectomy is an excellent option. Removal of the prostate with negative surgical margins can be achieved with a high frequency. Patients are afforded these curity of an undetectable PSA postoperatively which helps eliminate some of the inherent concerns which go along with an untreated or inadequately treated tumor. Recent modifications in surgical approach, including laparoscopic and robotic-assisted surgery, have lessened even further the impact of surgery on quality of life. Conclusion  Some patients with low risk disease who undergo radical prostatectomy are over treated and cured of a cancer which may not have been a significant threat to life or health. However, the uncertainty of active surveillance leads many patients to pursue curative therapy and radical prostatectomy offers an extremely low risk of death from prostate cancer, even with long term follow-up. Erectile dysfunction remains a potential quality of life compromise for some patients but, otherwise, the overwhelming majority return to their preoperative status within a short time with minimal risk for quality of life compromise.     

The relationship between quality and costs: factors that affect the hospital costs of radical prostatectomy

The present study seeks to establish a relationship between the quality of a surgical procedure and the subsequent hospital costs for that procedure by investigating the influence of both patient and peri-operative factors on the hospital costs of radical prostatectomy. All men who underwent radical prostatectomy at one institution during an 18-month period were included in this study. Clinical information was obtained from medical records and cost information was obtained from hospital billing data. The medical record was also used to determine peri-operative information such as operating room time, anesthesia time, surgical time, blood loss and units of packed red blood cells transfused. The correlation between costs and both clinical and peri-operative factors were determined using the Pearson correlation co-efficient. One hundred and four men underwent radical prostatectomy at our institution during the time period studied. Mean age of these patients was 60.2 y and mean length of stay for these patients was 3.4 days with a range of 2-10 days. Mean total hospital costs for this cohort was $5305 with a range of $2851-$10 358. Significant correlations with total hospital costs included operating room time, surgical time, estimated blood loss and blood transfused. Patient factors such as age, ASA class, co-morbidities and smoking history were not correlated with total hospital costs. The present study demonstrates that factors at least partially controlled by the surgeon such as surgical time and units of blood transfused directly influence the total hospital costs of radical prostatectomy, while patient factors such as age and the presence of co-morbidities had no significant correlation with total hospital costs. These findings demonstrate that surgeons can impact health care costs by providing high quality care and begins to establish a relationship between high quality care and low cost care.Prostate Cancer and Prostatic Diseases (2001) 4, 213-216.     

Radical prostatectomy: Surgical planning,execution, and outcomes

Open radical prostatectomy has evolved in the past 25 years to become the standard of care for most clinically significant tumors localized to the prostate gland. This operation effectively interrupts the natural progression of prostate cancer, yet it is sensitive to nuances in surgical technique and execution that affect cancer control and perioperative and functional outcomes. In general, surgical technique improves with experience, yet involves a steep learning curve that typically requires a couple hundred cases to overcome. Moreover, there is significant variability in outcomes even among experienced surgeons. Surgeons beginning practice and those adopting new techniques, such as robotics, should measure results carefully, realizing that there may be an oncologic learning curve different from that needed to execute the procedure. This article recognizes the formidable challenges for randomized clinical trials (eg, assuring stratification among surgeons in terms of randomization and demonstrating the absence of significant heterogeneity among providers that may explain differences among arms). Research is needed to identify the most effective technical steps that can be taught through formal educational programs.     

Radical prostatectomy and prostate cancer screening: the need for national audit and research.

Public awareness of prostate cancer is increasing. Growing numbers of middle-aged men are seeking screening tests for prostate cancer and advice about its surgical treatment. Contrary to the hopes of many, the benefit of early diagnosis and by radical prostatectomy remains in doubt. Recent analyses suggest that ''watchful waiting'', with no immediate treatment, may be an equally effective option. If this is true, why screen? Why operate? These questions should be a cause of concern to more than 1 million British men who are unaware that they have prostate cancer and to the providers of health care who have failed to address this dilemma. A national audit and randomised clinical trial are indicated.     

Radical prostatectomy: options and issues

Radical prostatectomy is an effective treatment for patients with clinically localized prostate cancer and is associated with a very low level of mortality. However, many men with untreated clinically localized prostate cancer do not die from the disease and, following radical prostatectomy, some patients will suffer from a loss of potency and/or incontinence. A major challenge faced by the clinician is to identify the individual patient who will benefit from radical prostatectomy. In this review, we discuss the natural history of clinically localized prostate cancer and the factors likely to affect the treatment decision for an individual patient. Recent studies by other investigators and ourselves have revealed that the T1/T2 tumour is heterogeneous with respect to pathological stage and outcome, and that the quantity of Gleason grade 4/5 tumour is a significant prognostic factor predicting lymph node progression and capsular penetration. Classification and Regression Trees (CART) analysis including such preoperative parameters can be used to predict the probability of an individual patient having a pT2 tumour and, therefore, whether he could have a nerve-sparing radical prostatectomy - a procedure which offers better outcomes in terms of potency and continence.     

Anastomotic strictures following radical prostatectomy: risk factors and management

Stricture of the anastomosis between the bladder neck and membranous urethra after radical prostatectomy can cause significant voiding dysfunction. Of 156 patients undergoing radical prostatectomy for localized prostatic carcinoma 18 had anastomotic stricture for an over-all incidence of 11.5%. The risk factors for anastomotic stricture and the treatment outcome in these patients were analyzed. Excessive intraoperative blood loss, extravasation of urine at the anastomotic site and a prior transurethral prostatic operation significantly contributed to the development of stricture. More than half of the patients did not respond to simple dilation alone. Cold knife incision of the stricture by itself was effective in only 62% of the patients. The remaining patients required periodic dilation to maintain an adequate urine flow. Incision of the stricture with electrocautery resulted in urinary incontinence in all patients.     

Radical prostatectomy: geographic and demographic variation

OBJECTIVES: Previous reports have documented a geographic variation in the use of radical prostatectomy. We examined whether this phenomenon can be explained by factors other than geography alone. METHODS: This study was based on the data from nine geographic regions of the Surveillance, Epidemiology, and End Results (SEER) program for the years 1983 through 1994. Patients with localized or regional prostate cancer were included in the analysis. Logistic regression analysis was used to investigate the influence of geographic and demographic factors on the use of radical prostatectomy. The squared multiple correlation coefficient R(2) was used to measure the proportion of variation in the selection of radical prostatectomy explained by each factor of interest. RESULTS: As previously reported, the use of radical prostatectomy was significantly associated with geographic location; the degree of geographic variation varied as a function of age and was most dramatic in the youngest (younger than 45 years) and the oldest (75 years or older) groups. Overall, however, geography explained less than 2% of the total variation in the use of radical prostatectomy. Age was the most important factor that influenced the use of radical prostatectomy. CONCLUSIONS: Geography explains only a small proportion of the variation in the use of radical prostatectomy. In fact, of the factors examined, only age appeared to meaningfully explain the variation in the use of radical prostatectomy. Overall, our ability to explain the variation in the use of radical prostatectomy remains meager, and new factors must be identified if we are to better understand how patients and physicians make clinical decisions.     

Radical prostatectomy: Positive surgical margins matter

ObjectiveA positive surgical margin (PSM) in the radical prostatectomy (RP) specimen is associated with biochemical recurrence (BCR) and the need for adjuvant radiation therapy, and is a surrogate for surgical quality. We review the available data describing the identification, anatomy, and management of PSM after RP.MethodsA PubMed search (using English language as a filter) was performed to identify factors affecting PSMs and their management.ResultsPSMs are associated with an increased likelihood of BCR after RP. The most common location for a PSM is the apex, followed by the posterolateral edge of the prostate. The risk of recurrence in a patient with a PSM is associated with the location, length, and Gleason score of the PSM. The management of a patient with a PSM remains controversial, with some recommending adjuvant radiation therapy for all PSMs and others suggesting only salvage radiation therapy for men who experience BCR.ConclusionsPSMs are associated with an increased likelihood of BCR and often result in initiation of adjuvant treatment. Therefore, the goal of surgery should be to minimize the likelihood of a PSM.     

Early infection after hip fracture surgery: risk factors, costs and outcome

Prospective data on hip fracture from 3686 patients at a United Kingdom teaching hospital were analysed to investigate the risk factors, financial costs and outcomes associated with deep or superficial wound infections after hip fracture surgery. In 1.2% (41) of patients a deep wound infection developed, and 1.1% (39) had a superficial wound infection. A total of 57 of 80 infections (71.3%) were due to Staphylococcus aureus and 39 (48.8%) were due to MRSA. No statistically significant pre-operative risk factors were detected. Length of stay, cost of treatment and pre-discharge mortality all significantly increased with deep wound infection. The one-year mortality was 30%, and this increased to 50% in those who developed an infection (p < 0.001). A deep infection resulted in doubled operative costs, tripled investigation costs and quadrupled ward costs. MRSA infection increased costs, length of stay, and pre-discharge mortality compared with non-MRSA infection.     

Thrombotic risk factors associated with transurethral prostatectomy.

OBJECTIVE: To ascertain the potential thrombotic risk associated with transurethral prostatectomy (TURP). PATIENTS AND METHODS: The changes in coagulation variables were assessed in a prospective study of 40 patients undergoing TURP. RESULTS: There was a significant increase in thrombin-antithrombin complexes 6 h after TURP (anova, P=0.01) combined with a significant decrease in activated partial thromboplastin time (anova, P=0.006), suggesting a postoperative hypercoagulable state. The significant increase in d-dimer 24 h after TURP (anova, P=0.015) in the absence of any significant rise in tissue plasminogen activator antigen levels perioperatively (anova, P=0.737) suggests a physiological fibrinolytic response to the developing procoagulant state. The absence of any significant increase in plasminogen activator inhibitor-1 antigen perioperatively (anova, P=0.348) suggests the observed hypercoagulability is not due to a 'fibrinolytic shutdown' reported in other forms of surgery. CONCLUSION: TURP is associated with a hypercoagulable prothrombotic state; aspirin withdrawal perioperatively may be hazardous, and low-dose heparin prophylaxis for venous thrombosis should be considered.     

Radical prostatectomy: Time trends, morbidity and quality of life

In recent years, increased screening for prostate cancer, primarily with prostate-specific antigen testing, has led to an apparent increase in the incidence of prostate cancer and resulted in a shift to an earlier patient age and tumor stage at diagnosis. From the early 1980s, there have been great advances in surgical technique. In the 1990s, radical prostatectomy gained popularity among Japanese urologists. Time trends and morbidity of contemporary anatomical radical prostatectomy in Japan are reported here. In addition, the quality of life in men undergoing radical prostatectomy is discussed.