Aakash Keswani

Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends

BACKGROUND This study aimed to compare risk of postdischarge adverse events in elective total joint arthroplasty (TJA) patients by discharge destination, identify risk factors for inpatient discharge placement and postdischarge adverse events, and stratify TJA patients based on these risk factors to identify the most appropriate discharge destination. METHODS Patients who underwent elective primary total hip or knee arthroplasty from 2011 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were assessed using perioperative variables. RESULTS A total of 106,360 TJA patients were analyzed. The most common discharge destinations included home (70%), skilled nursing facility (SNF) (19%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed that rates of postdischarge adverse events were higher in SNF and IRF patients (all P ≤ .001). In multivariate analysis controlling for patient characteristics, comorbidities, and incidence of complication predischarge, SNF and IRF patients were more likely to have postdischarge severe adverse events (SNF: odds ratio [OR]: 1.46, P ≤ .001; IRF: OR: 1.59, P ≤ .001) and unplanned readmission (SNF: OR: 1.42, P ≤ .001; IRF: OR: 1.38, P ≤ .001). After stratifying patients by strongest independent risk factors (OR: ≥1.15, P ≤ .05) for adverse outcomes after discharge, we found that home discharge is the optimal strategy for minimizing rate of severe 30-day adverse events after discharge (P ≤ .05 for 5 out of 6 risk levels) and unplanned 30-day readmissions (P ≤ .05 for 6 out of 7 risk levels). Multivariate analysis revealed incidence of severe adverse events predischarge, female gender, functional status, body mass index >40, smoking, diabetes, pulmonary disease, hypertension, and American Society of Anesthesiologists class 3/4 as independent predictors of nonhome discharge (all P ≤ .001). CONCLUSION SNF or IRF discharge increases the risk of postdischarge adverse events compared to home. Modifiable risk factors for nonhome discharge and postdischarge adverse events should be addressed preoperatively to improve patient outcomes across discharge settings.

Outcomes, complications, utilization trends, and risk factors for primary and revision total elbow replacement.

BACKGROUND Using a validated database, 30-day complications of primary and revision total elbow arthroplasty (TEA) were analyzed to identify risk factors of adverse events. METHODS Primary and revision TEAs from 2007 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses of risk factors for 30-day adverse events were assessed using preoperative and intraoperative variables. RESULTS The study reviewed 189 primary and 53 revision TEA patients. Fracture (34%), osteoarthritis (24%), and rheumatoid arthritis (23%) were the most common indications for TEA. Adverse event rate was similar in primary and revision TEA (12% vs. 15%; P = .49), and infectious complications occurred in 3.2% of primary TEAs and 7.5% of revision TEAs (P = .23). Bivariate analysis of risk factors for 30-day adverse events identified dependent functional status in primary TEA (P = .03) and age in revision TEA (P = .02). Multivariate analysis of primary TEA revealed that adverse events were significantly less likely with rheumatoid arthritis compared with osteoarthritis etiology (odds ratio, 0.15; P = .02), and smoking was associated with an increased chance of infection (odds ratio, 6.96; P = .03). Revision TEA was not associated with an increased 30-day adverse event or infection rate compared with primary TEA in multivariate analysis. Among primary and revision TEA patients, dependent functional status (P = .02) and hypertension (P = .04) were independent predictors for adverse events. CONCLUSION Modifiable risk factors should be addressed before TEA to limit postoperative complications as well as cost. The risk of short-term complications after revision TEA is comparable to that of primary TEA.

What Quality Metrics Is My Hospital Being Evaluated on and What Are the Consequences

Quality, experience, and cost are important indicators of value to patients. However, stakeholders have yet to reach agreement on how to define quality and which measures should be used to assess quality. Measures that have been used to assess quality in health care include structural, process, patient experience, efficiency, and outcomes measures. Payers and other quality rating organizations use a combination of measures to rate or rank hospitals on the quality of care they provide. These ratings can be strictly informational or can be used to steer patients, for contracting between payers and providers, and more recently, for adjustments to reimbursements. Physicians and hospitals have a crucial role to play in the development of quality measures that are used to measure and improve value. Consensus on quality measures will facilitate meaningful comparisons across providers and insights that will enable improvements in the value of care we deliver to our patients.

Risk Factors Predict Increased Length of Stay and Readmission Rates in Revision Joint Arthroplasty

BACKGROUND This study aimed to identify risk factors for 30-day readmission and extended length of stay (LOS) in revision total knee (RKA) and hip (RHA) arthroplasty patients. METHODS Patients who underwent RKA or RHA from 2011 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses of risk factors for 30-day readmission and extended LOS (>75th percentile) were assessed using preoperative and intraoperative variables. RESULTS A total of 4977 RKA and 5135 RHA patients were reviewed. The most common causes for revision were mechanical (52% RKA, 52% RHA), infection (13% RKA, 8% RHA), dislocation (6% RKA, 13% RHA), and fracture (1% RKA, 4% RHA). Rate of readmission for RKA patients (6.4%; 318 patients) was lower than for RHA patients (8.0%; 409 patients) (P = .002). Multivariate analysis identified severe adverse event before discharge, male sex, pulmonary disease, stroke, cardiac disease, and American Society of Anesthesiologists class 3 or 4 as significant predictors of readmission (all P ≤ .03). Surgical complications were the more common cause of readmission for both groups. Multivariate analysis of extended LOS identified infection or fracture etiology relative to mechanical loosening etiology, functional status, body mass index greater than 40 kg/m2, history of smoking, diabetes, cardiac disease, stroke, bleeding-causing disorders, wound class 3 or 4, and American Society of Anesthesiologists class 3 or 4 (all P ≤ .05) as independent predictors. CONCLUSION Modifiable risk factors should be addressed prior to revision total joint arthroplasty to reduce 30-day readmissions and LOS. Future P4P revision arthroplasty models should incorporate procedural diagnosis as rates of readmission and extended LOS significantly differ across procedural etiologies.

Discharge Destination After Revision Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes and Placement Risk Factors

BACKGROUND Given the rising incidence of revision total joint arthroplasty (RJR), bundled payments will likely be applied to RJR in the near future. This study aimed to compare postdischarge adverse events by discharge destination, identify risk factors for discharge placement, and stratify RJR patients based on these risk factors to identify the most appropriate discharge destination. METHODS Patients that underwent revision total hip or knee arthroplasty from 2011 to 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Analysis of risk factors was assessed using preoperative and intraoperative variables. RESULTS A total of 9973 RJR patients from 2011 to 2013 were included for analysis. The most common discharge destination included home (66%), skilled nursing facility (SNF; 23%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed higher rate of postdischarge 30-day severe adverse events (6.1% vs 4.1%, P < .001) and unplanned readmissions (9.3% vs 6.1%, P < .001) in nonhome vs home patients. In multivariate analysis, SNF and IRF patients were 1.30 and 1.51 times more likely to suffer an unplanned 30-day readmission relative to home patients (P ≤ .01), respectively. After stratifying patients by number of significant risk factors and discharge destination, IRF patients consistently had significantly higher rates of unplanned 30-day readmission than home patients (P ≤ .05). CONCLUSION RJR patients who are discharged to SNF or IRF have significantly increased risk for unplanned readmissions as compared with patients discharged home. Across risk levels, home discharge destination (when feasible) is the optimal strategy compared with IRF, although the distinction between SNF and home is less clear.

Nonoperative Versus Operative Treatment of Displaced Ankle Fractures in Diabetics.

Background: Diabetes is a risk factor for complications related to displaced ankle fractures. Limited literature exists comparing complication rates in nonoperative versus operative treatment of displaced ankle fractures in diabetics. No study has highlighted the natural history of nonoperative treatment of displaced ankle fractures in diabetics. Methods: We retrospectively reviewed all adult ankle fractures from September 2011 through December 2014. Inclusion was limited to ambulatory adults (>18 years) with closed, displaced (widened mortise) ankle fractures with diabetes mellitus. Nonoperative treatment consisted of closed reduction and casting. Fractures were classified according to the Lauge-Hansen and AO-Weber classification systems. All operative fractures underwent open reduction internal fixation (ORIF) within 3 weeks of injury. Functional outcomes and complication rates were compared. Of 28 displaced diabetic ankle fractures, 20 were treated nonoperatively (closed reduction and casting) and 8 operatively (ORIF within 3 weeks of injury). Mean follow-up was 7 months (range 3-18 months). Results: Age, insulin-dependent diabetes, and AO type B fracture rate were similar in nonoperative and operative cohorts, but fracture dislocation rate was significantly higher among operative fractures (87.5% vs 40%; P = .04). Nonoperative treatment was associated with a 21-fold increased odds of complication compared with operative treatment (75% vs 12.5%, OR 21.0, P = .004). Complication rate following unintended ORIF for persistent nonunion or malunion in nonoperatively treated patients was significantly greater compared with immediate ORIF (100% vs 12.5%, P = .005). Conclusion: Nonoperative treatment of displaced diabetic ankle fractures was associated with unacceptably high complication rates when compared to operative treatment. Level of Evidence: Level III, retrospective comparative series.

Atypical femur fracture during bisphosphonate drug holiday: a case series.

Recent studies have noted an increased risk of low energy subtrochanteric and femoral shaft fractures termed “atypical femur fractures” (AFFs) associated with long-term bisphosphonate use. As such, many clinicians have begun recommending a “drug holiday” to reduce the risks associated with long-term bisphosphonate use. We present two cases of AFFs occurring during a 4-year or greater drug holiday following long-term bisphosphonate use. These findings highlight the need to reevaluate optimal bisphosphonate therapy duration, dosage, as well as initiation and duration of a drug holiday with continued monitoring in the prevention of AFFs.

Risk factors for and timing of adverse events after total shoulder arthroplasty

BACKGROUND Total shoulder arthroplasty (TSA) is a likely target for future bundled payment initiatives, necessitating accurate preoperative risk stratification. The purpose of this study was to identify risk factors for unplanned readmission and severe adverse events, to risk stratify TSA patients based on these risk factors, and to assess timing of complications after TSA. METHODS Data were collected from patients undergoing TSA from 2009 to 2014 in the American College of Surgeons National Surgical Quality Improvement Program. Bivariate and multivariate analyses of risk factors for severe adverse events or readmission were assessed. Patients were risk stratified, and timing of severe adverse events and cause of readmission were evaluated. RESULTS The analysis included 5801 TSA patients; 146 (2.5%) suffered severe adverse events, and 158 (2.7%) had a 30-day unplanned readmission. The most common severe adverse events were reoperation (40%), thrombolic event (deep venous thrombosis or pulmonary embolism; 14%), cardiac event (10%), and death (8.2%). Pneumonia (8.9%) and thrombolic event (7.6%) were the most common medically related causes, whereas dislocation (7.6%) and postoperative infection or wound complication (5.1%) were the most common surgical causes for readmission. Multivariate analysis identified inflammatory arthritis (P = .026), male gender (P = .019), age (P < .001), functional status (P = .024), and American Society of Anesthesiologists class 3/4 (P = .01) as independent predictors for unplanned 30-day readmission and all but inflammatory arthritis for severe adverse events (P ≤ .05 for all). Patients with ≥3 risk factors had an 11.56 (P = .002) and 3.43 (P = .013) times increased odds of unplanned readmission and severe adverse events occurring within 2 weeks after surgery, respectively, compared with patients with 0 risk factors. CONCLUSIONS Patients at high risk of TSA complications and readmission should be identified preoperatively to improve outcomes and to lower costs. Bundled payment initiatives must account for both patient- and procedure-related risk factors.

Intramedullary Nail Fixation of Atypical Femur Fractures With Bone Marrow Aspirate Concentrate Leads to Faster Union: A Case–control Study

OBJECTIVES High rates of implant failure and nonunion in atypical femur fractures (AFF) have been reported. The aim of this study was to evaluate bone marrow aspirate concentrate (BMAC) use in the treatment of AFF. DESIGN Retrospective Case Control SETTING:: Level 1 Trauma Center PATIENTS:: Complete AFF, defined according to American Society of Bone and Mineral Research (ASBMR) criteria, from September 2009 to April 2015 with minimum 1 year follow up. INTERVENTION Operative treatment with anterograde intramedullary (IM) nails. Beginning June 2014, BMAC from the ipsilateral iliac crest was added to all AFFs. MAIN OUTCOME MEASUREMENTS Time to union as determined by a blinded panel of 3 Attending Orthopaedic Surgeons, union rates, complications. RESULTS 35 patients with 36 AFFs were reviewed, of which 33 AFFs were included and 11 received BMAC. Aledronate was the most commonly prescribed bisphosphonate, with a similar mean duration of use in controls and BMAC cases (5.6 vs 6 years, p=0.79). BMAC use significantly decreased time to union (3.5 vs 6.8 months, p=0.004). Varus malreduction was associated with a significant delay in union (9.7 vs 4.7 months, p=0.04). Overall one year union rate was 86.2%, and nonsignificantly higher in BMAC compared to controls (100.0% vs. 77.3%, p=0.11). Multivariate analysis revealed BMAC and varus malreduction as independent predictors of time to union. There were no complications related to BMAC use. CONCLUSION Our findings support IM nailing of AFF as an effective treatment option with a low surgical complication rate and highlight the importance of avoiding varus malreduction. BMAC use significantly reduced time to fracture union without an increase in surgical complication rates. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.Objectives: To evaluate bone marrow aspirate concentrate (BMAC) use in the treatment of AFF. Design: Retrospective case control. Setting: Level 1 trauma center. Patients: Complete AFF, defined according to American Society of Bone and Mineral Research (ASBMR) criteria, from September 2009 to April 2015 with minimum 1-year follow-up. Intervention: Operative treatment with antegrade intramedullary nails. Beginning June 2014, BMAC from the ipsilateral iliac crest was added to all AFFs. Main Outcome Measurements: Time to union as determined by a blinded panel of 3 attending orthopaedic surgeons, union rates, complications. Results: Thirty-five patients with 36 AFFs were reviewed, of which 33 AFFs were included and 11 received BMAC. Alendronate was the most commonly prescribed bisphosphonate, with a similar mean duration of use in controls and BMAC cases (5.6 versus 6 years, P = 0.79). BMAC use significantly decreased time to union (3.5 versus 6.8 months, P = 0.004). Varus malreduction was associated with a significant delay in union (9.7 versus 4.7 months, P = 0.04). Overall, 1 year union rate was 86.2% and nonsignificantly higher in BMAC compared with controls (100.0% versus 77.3%, P = 0.11). Multivariate analysis revealed BMAC and varus malreduction as independent predictors of time to union. There were no complications related to BMAC use. Conclusion: Our findings support intramedullary nailing of AFFs as an effective treatment option with a low surgical complication rate and highlight the importance of avoiding varus malreduction. BMAC use significantly reduced time to fracture union without an increase in surgical complication rates. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nonelective Primary Total Hip Arthroplasty: The Effect of Discharge Destination on Postdischarge Outcomes

BACKGROUND Medicare has enacted a mandatory bundled payment program for primary total joint arthroplasty that includes nonelective primary total hip arthroplasty (THA). Efficient postacute care management has been identified as an opportunity to improve value for patients. We aimed to identify risk factors for and compare rates of complications by discharge destination and then use those factors to risk-stratify non-elective THA patients. METHODS Patients who underwent nonelective primary THA from 2011 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database and categorized into those discharged to skilled nursing facility or inpatient rehabilitation facility vs home self-managed/home health (HHH). Bivariate and multivariate analyses of risk factors for postdischarge adverse events were performed using patient characteristics and intraoperative variables. RESULTS In bivariate analysis, skilled nursing facility or inpatient rehabilitation facility patients compared with HHH patients, had lower rates of postdischarge severe adverse events (SAEs; 49% vs 58%; P < .001) and unplanned 30-day readmissions (71% vs 83%; P < .001). HHH discharged patients with 1 or more of risk factors had a 1.85-6.18 times odds of complications within the first 14 days. CONCLUSION The most important risk factors for predicting postdischarge SAE and readmission are predischarge SAE, dependent functional status, body mass index >40 kg/m2, smoking, diabetes, chronic steroid use, and American Society of Anesthesiologists class 3/4. Nonelective THA patients without these risk factors may be safely discharged to home after THA. Orthopedic surgeons and their nonelective THA patients must agree on the most appropriate discharge destination through a shared decision-making process that takes into account these significant risk factors and other psychosocial factors.