Effects of a Total Knee Arthroplasty Care Pathway on Cost,Quality, and Patient Experience: Toward Measuring the Triple Aim

BackgroundCare pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience.MethodsA historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.ResultsIn total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (?8.501%, 95% confidence interval [CI] ?9.639 to ?7.350), a decrease in LOS (?26.966%, 95% CI ?28.516 to ?25.382), and an increase in discharges to home (odds ratio [OR] 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient.ConclusionTKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually.     

Periurethral injection of autologous fat for the treatment of post-fistula repair stress incontinence: A preliminary report

The aim of the study was to asses the effectiveness of periurethral injection of autologous fat for the treatment of stress incontinence caused by inherent sphincter weakness in women following the repair of obstetric urogenital fistulae. Ten patients with symptomatic stress incontinence following repair of vesicovaginal or urethrovaginal fistula of obstetric origin were assessed clinically, by cystourethroscopy, and by Valsalva leak-point pressure (VLPP). Four showed some degree of bladder neck mobility and were treated by bladder neck suspension procedures. Six appeared to have pure sphincter weakness and were treated by periurethral injection of autologous fat. For logistic reasons, the initial follow-up was undertaken 2 weeks postoperatively, including clinical assessment and VLPP. Two patients were subjectively cured, 2 improved and 2 perceived no change in their symptoms following the procedure. The symptomatic changes correlated with the operative appearance, and with the subsequent changes in VLPP. Although numbers are small and follow-up short, we feel that these preliminary results justify further investigation of the technique in this most difficult group of patients.EDITORIAL COMMENT: The authors report an original concept for the treatment of intrinsic sphincter deficiency following obstetrical vesicovaginal fistula repair. Although preliminary, based on the authors' experience with a small group of patients and with minimal follow-up, this pilot study paves the way for future work in this area. The patients served have limited options for treatment from several aspects, including the severity of their incontinence, tissue health in the urogenital area, overall health, limited availability of other surgical options and general inaccessibility of medical care. The use of autologous fat for periurethral injection in this population of patients, where medical resources are limited, represents a simple, minimally invasive and relatively inexpensive option with possibly realistic success rates. Further investigation on the use of this technique to treat post-vesicovaginal fistula repair of intrinsic sphincter deficiency is needed to fully assess its applicability and success.     

Prevalence of osteoporosis in women referred for bone density testing: utility of multiple skeletal sites.

The objective of this study was to determine retrospectively the prevalence of osteoporosis in a referral population and to compare the effectiveness of measuring multiple skeletal sites for identifying osteoporosis. Although osteoporosis is considered to be a major public health problem in the United States, and there are reliable methods for diagnosis based on bone densitometry, fewer than 25% of cases are currently identified. There is no consensus about which skeletal site(s) should be measured for optimal results. In this study, bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (DXA) at the radius (proximal site), lumbar spine, femoral neck, and total proximal femur regions in 537 consecutive white females age 50 and older referred by community physicians for bone densitometry. The prevalence of osteopenia and osteoporosis (based on the World Health Organization definitions) was determined, as well as the incidence of misclassification of patients based on different skeletal sites. Overall, 53.3% had osteoporosis, an additional 37.7% had osteopenia, and only 8.7% had normal BMD at all measurement sites. The prevalence was similar at all measurement sites and the incidence of misclassification was low. Given the magnitude of undetected osteoporosis and the efficacy of bone densitometry at any skeletal site, these data have important implications for the optimal deployment of bone density measurement facilities.     

Motor subtype and cognitive decline in Parkinson's disease, Parkinson's disease with dementia, and dementia with Lewy bodies

BACKGROUND: A previous cross sectional study found over-representation of a postural instability gait difficulty (PIGD) motor subtype in Parkinson's disease patients with dementia (PDD) and dementia with Lewy bodies (DLB), compared with Parkinson's disease (PD). AIMS: (1) To examine rates of cognitive and motor decline over two years in PD (n=40), PDD (n=42) and DLB (n=41) subjects, compared with age matched controls (n=41), (2) to record whether motor phenotypes of PD, PDD, and DLB subjects changed during the study, (3) to find out if cognitive and motor decline in PD was associated with baseline motor subtype, and (4) to report the incidence of dementia in PD patients in relation to baseline motor subtype. RESULTS: Most of PDD and DLB participants were PIGD subtype at baseline assessment. In the non-demented PD group, tremor dominant (TD) and PIGD subtypes were more evenly represented. Cognitive decline over two years was greater in PDD and DLB groups (mean decline in MMSE -4.5 and -3.9, respectively), compared with PD (-0.2) and controls (-0.3). There was an association between PIGD subtype and increased rate of cognitive decline within the PD group. Of 40 PD patients, 25% of the 16 PIGD subtype developed dementia over two years, compared with none of the 18 TD or six indeterminate phenotype cases (chi2=6.7, Fisher's exact test p<0.05). CONCLUSION: A PIGD motor subtype is associated with a faster rate of cognitive decline in PD and may be considered a risk factor for incident dementia in PD.     

Detection of colonic polyps on single-contrast barium enema study: emphasis on the elderly

A systems approach was employed to improve results of the single-contrast barium enema examination for detection of colonic polyps. Improvements were made in each of the following areas: radiographic-fluoroscopic equipment, fluoroscopic-television images, screen-film combinations, barium suspensions, examination techniques, imaging sequences, and quality controls. Radiologic-endoscopic correlation was undertaken for 137 colonic polyps seen endoscopically in 91 patients. The average age of the patients was 69 years. The sensitivity of the single-contrast examination for detection of all polyps was 80%. Polyps 5-9 mm in size were detected with 66% sensitivity, while 94% of polyps 10 mm or larger were detected. The results indicate that the sensitivity of a suitably performed single-contrast barium enema examination may approach that of the double-contrast study for the detection of colonic polyps, even in an elderly and infirm patient population.     

Postpartum pituitary hypophysitis.

The case of a young woman who developed lymphocytic hypophysitis 2 weeks after delivery of a healthy baby is reported. The patient presented with clinical features suggestive of a pituitary mass lesion, but surgery was avoided when other clinical and radiologic features were considered. The patient recovered with steroid treatment only. We review the literature on this increasingly recognized condition and argue that medical management may be more suitable than previously thought.     

A clonally distinct recurrence of Burkitt's lymphoma at 15 years

A human immunodeficiency virus-negative male was successfully treated for two occurrences of Burkitt's lymphoma, 15 years apart. As consolidation of his second remission, he underwent high-dose chemotherapy with peripheral blood stem cell transplantation. In an effort to prove whether the second lymphoma was a relapse of the first or a second primary lymphoma, we obtained paraffin-embedded material from both lymphomas. DNA was extracted from this material and amplified by polymerase chain reaction (PCR) using consensus JH and VH region primers. Analysis of the PCR products, which mostly reflects VDJ joints, showed two sharp bands of different molecular size, proving the monoclonal nature of the lymphomas and suggesting that each had different Ig gene rearrangements. Sequencing of both PCR products showed a marked dissimilarity in nucleotide sequence in the clonally unique VDJ joint region, providing strong evidence for the separate cellular genesis of each lymphoma. These results suggest that late relapses of Burkitt's lymphoma should be examined for clonal distinctiveness. If the second lymphoma is distinct from the primary one, it might be treated as a primary lymphoma rather than as recurrent disease.     

Single-acquisition chemical-shift imaging of a binary system with use of stimulated echoes

A method for separating binary chemical-shift components with a single image data acquisition by means of stimulated echoes is demonstrated. With a strategy analogous to the modified Dixon method, three stimulated echoes were acquired to form three complex images. In each of the images, the complex pixel intensities were imparted, by design of the pulse sequence, with a phase factor carrying chemical-shift or field inhomogeneity information. With these three images, true fat/water separation can be obtained in biologic tissues. Studies at high field strength (4.7 T) on a toluene phantom, a pseudo-binary chemical-shift system, were used to evaluate the applicability of the method. Its clinical feasibility was demonstrated on a healthy human subject in a 0.6-T whole-body imaging system.