Benjamin J. Keeney

Predictors of Facility Discharge, Range of Motion, and Patient-Reported Physical Function Improvement After Primary Total Knee Arthroplasty: A Prospective Cohort Analysis

BACKGROUND Patients are discharged to home or inpatient settings after primary unilateral total knee arthroplasty (TKA). Few studies have compared patient outcomes following these 2 rehabilitation models for TKA patients. We identified predictors of inpatient discharge, 3-month postoperative range of motion (ROM), and 3-month postoperative patient-reported physical function improvement (Veterans RAND 12-Item Physical Component Score [PCS]) between these discharge settings. METHODS We studied prospectively collected cohort data for 738 TKAs between April 2011 and April 2013 at a high-volume tertiary academic medical center in a rural setting. All patients followed a standardized care pathway that involved prospective data collection as part of routine clinical care. Adjusting variables included age, sex, preoperative PCS, surgeon, modified Charlson Comorbidity Index, preoperative body mass index, laterality, and preoperative ROM; the 3-month models also included length of stay and discharge disposition as adjusters. RESULTS Significant adjusted predictors of inpatient discharge included older age, female sex, surgeon, comorbidity, lower PCS, and body mass index greater than 40. Only lower preoperative ROM predicted postoperative ROM. Inpatient discharge and higher preoperative PCS predicted lower PCS improvement. Home-based rehabilitation was associated with greater 3-month PCS improvement and showed no difference with 3-month ROM. CONCLUSION Discharge to home-based rehabilitation after TKA, rather than inpatient facility, is associated with higher physical function at 3 months postsurgery and shows no difference with 3-month ROM. Total knee arthroplasty inpatient discharge should be based on patient care requirements rather than perceived benefit of improved ROM and physical function.

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State

Study Design. Prospective population-based cohort study. Objective. To identify early predictors of lumbar spine surgery within 3 years after occupational back injury. Summary of Background Data. Back injuries are the most prevalent occupational injury in the United States. Few prospective studies have examined early predictors of spine surgery after work-related back injury. Methods. Using Disability Risk Identification Study Cohort (D-RISC) data, we examined the early predictors of lumbar spine surgery within 3 years among Washington State workers, with new workers compensation temporary total disability claims for back injuries. Baseline measures included worker-reported measures obtained approximately 3 weeks after claim submission. We used medical bill data to determine whether participants underwent surgery, covered by the claim, within 3 years. Baseline predictors (P < 0.10) of surgery in bivariate analyses were included in a multivariate logistic regression model predicting lumbar spine surgery. The area under the receiver operating characteristic curve of the model was used to determine the models ability to identify correctly workers who underwent surgery. Results. In the D-RISC sample of 1885 workers, 174 (9.2%) had a lumbar spine surgery within 3 years. Baseline variables associated with surgery (P < 0.05) in the multivariate model included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and surgeon as first provider seen for the injury. Reduced odds of surgery were observed for those younger than 35 years, females, Hispanics, and those whose first provider was a chiropractor. Approximately 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. The area under the receiver operating characteristic curve of the multivariate model was 0.93 (95% confidence interval, 0.92–0.95), indicating excellent ability to discriminate between workers who would versus would not have surgery. Conclusion. Baseline variables in multiple domains predicted lumbar spine surgery. There was a very strong association between surgery and first provider seen for the injury even after adjustment for other important variables.

Provider Perceptions of the Electronic Health Record Incentive Programs: A Survey of Eligible Professionals Who Have and Have Not Attested to Meaningful Use

ABSTRACTBACKGROUNDThe HITECH Act of 2009 enabled the Centers for Medicare & Medicaid Services (CMS) to provide financial incentives to health care providers who demonstrate “meaningful use” (MU) of their electronic health records (EHRs). Despite stakeholder involvement in the rule-making phase, formal input about the MU program from a cross section of providers has not been reported since incentive payments began.OBJECTIVETo examine the perspectives and experiences of a random sample of health care professionals eligible for financial incentives (eligible professionals or EPs) for demonstrating meaningful use of their EHRs. It was hypothesized that EPs actively participating in the MU program would generally view the purported benefits of MU more positively than EPs not yet participating in the incentive program.DESIGNSurvey data were collected by mail from a random sample of EPs in Washington State and Idaho. Two follow-up mailings were made to non-respondents.PARTICIPANTSThe sample included EPs who had registered for incentive payments or attested to MU (MU-Active) and EPs not yet participating in the incentive program (MU-Inactive).MAIN MEASURESThe survey assessed perceptions of general realities and influences of MU on health care; views on the influence of MU on clinics; and personal views about MU. EP opinions were assessed with close- and open-ended items.KEY RESULTSClose-ended responses indicated that MU-Active providers were generally more positive about the program than MU-Inactive providers. However, the majority of respondents in both groups felt that MU would not reduce care disparities or improve the accuracy of patient information. The additional workload on EPs and their staff was viewed as too great a burden on productivity relative to the level of reimbursement for achieving MU goals. The majority of open-ended responses in each group reinforced the general perception that the MU program diverted attention from treating patients by imposing greater reporting requirements.CONCLUSIONSSurvey results indicate the need by CMS to step up engagement with EPs in future planning for the MU program, while also providing support for achieving MU standards.

Measuring primary care organizational capacity for diabetes care coordination: the Diabetes Care Coordination Readiness Assessment.

ABSTRACTBACKGROUNDNot all primary care clinics are prepared to implement care coordination services for chronic conditions, such as diabetes. Understanding true capacity to coordinate care is an important first-step toward establishing effective and efficient care coordination. Yet, we could identify no diabetes-specific instruments to systematically assess readiness and/or status of primary care clinics to engage in diabetes care coordination.OBJECTIVEThis report describes the development and initial validation of the Diabetes Care Coordination Readiness Assessment (DCCRA), which is intended to measure primary care clinic readiness to coordinate care for adult patients with diabetes.DESIGNThe instrument was developed through iterative item generation within a framework of five domains of care coordination: Organizational Capacity, Care Coordination, Clinical Management, Quality Improvement, and Technical Infrastructure.PARTICIPANTSValidation data was collected on 39 primary care clinics.MAIN MEASURESContent validity, inter-rater reliability, internal consistency, and construct validity of the 49-item instrument were assessed.KEY RESULTSInter-rater agreement indices per item ranged from 0.50 to 1.0. Cronbach’s alpha of the entire instrument was 0.964, and for the five domain scales ranged from 0.688 to 0.961. Clinics with existing care coordinators were rated as more ready to support care coordination than clinics without care coordinators for the entire DCCRA and for each domain, supporting construct validity.CONCLUSIONSAs providers increasingly attempt to adopt patient-centered approaches, introduction of the DCCRA is timely and appropriate for assisting clinics with identifying gaps in provision of care coordination services. The DCCRA’s strengths include promising psychometric properties. A valid measure of diabetes care coordination readiness should be useful in diabetes program evaluation, assistance with quality improvement initiatives, and measurement of patient-centered care in research.

Preoperative body mass index and physical function are associated with length of stay and facility discharge after total knee arthroplasty

BACKGROUND Hospital length of stay (LOS) and facility discharge are primary drivers of the cost of total knee arthroplasty (TKA). We sought to identify modifiable patient factors that were associated with increased LOS and facility discharge after TKA. METHODS Prospective data were reviewed from 716 consecutive, primary TKA procedures performed by two arthroplasty surgeons between 2006 and 2012 at a single institution. Preoperative body mass index (BMI), Veterans RAND-12 (VR-12) physical component score (PCS), and hemoglobin level were collected in addition to other adjusters. Multivariate linear and logistic models were constructed to predict LOS and facility discharge, respectively. RESULTS After adjustment, higher BMI was associated with increased LOS in a dose-response effect: Compared to normal weight (BMI <25) overweight (25-29.9) was associated with longer LOS by 0.32days (P=0.038), class-I obesity (30-34.9) by 0.33days (P=0.024), class-II obesity (35-39.9) by 0.67days (P=0.012) and class-III obesity (>40) by 1.15days (P<0.001). Class-III obesity was associated with facility discharge (odds ratio=2.08, P=0.008). Poor PCS was associated with increasing LOS: compared to PCS≥50, PCS 20-29 was associated with a LOS increase of 0.40days (P=0.014) and PCS<20 with a LOS increase of 0.64days (P=0.031). CONCLUSION Patient BMI has a dose-response effect in increasing LOS. Poor PCS was associated similarly with increased LOS. These associations for of BMI and PCS suggest that improvement preoperatively, by any amount, may potentially translate to decreased LOS and perhaps lower the cost associated with TKA.

Clinically significant weight gain 1 year after occupational back injury.

Objective: To examine the incidence of clinically significant weight gain 1 year after occupational back injury, and risk factors for that gain. Methods: A cohort of Washington State workers with wage-replacement benefits for back injuries completed baseline and 1-year follow-up telephone interviews. We obtained additional measures from claims and medical records. Results: Among 1263 workers, 174 (13.8%) reported clinically significant weight gain (≥7%) 1 year after occupational back injury. Women and workers who had more than 180 days on wage replacement at 1 year were twice as likely (adjusted odds ratio = 2.17, 95% confidence interval = 1.54 to 3.07; adjusted odds ratio = 2.40, 95% confidence interval = 1.63 to 3.53, respectively; both P < 0.001) to have clinically significant weight gain. Conclusions: Women and workers on wage replacement for more than 180 days may be susceptible to clinically significant weight gain after occupational back injury.

Are Barbed Sutures Associated With 90-day Reoperation Rates After Primary TKA?

BackgroundStudies have suggested that barbed sutures for wound closure in TKAs are an acceptable alternative to standard methods. However others have observed a higher risk of wound-related complications with barbed sutures.Questions/Purposes(1) Do 90-day TKA reoperation rates differ between patients undergoing a barbed suture arthrotomy closure compared with a traditional interrupted closure? (2) Do the 90-day reoperation rates of wound-related, deep infection, and arthrotomy failure complications differ between barbed suture and traditional closures?MethodsA retrospective analysis of a longitudinally maintained institutional primary TKA database was conducted on all TKAs performed between April 2011 and September 2015. We compared 884 primary TKAs, where the arthrotomy was closed with a barbed suture, with 1598 primary TKAs closed with the standard interrupted suture. After barbed sutures were introduced at our institution in 2012, the majority of surgeons gradually switched to barbed suture closures, with many using them exclusively by the end of the data collection period. We confirmed in-person followups and available data past 90 days for 97.4% (1556 of 1598) of the knees in patients with standard sutures and 94.8% (838 of 884) of the knees in patients with barbed sutures. Our primary endpoint was all-cause 90-day reoperation; our secondary endpoints considered: wound-related reoperation, as defined by previous studies; deep infection per Musculoskeletal Infection Society guidelines; and arthrotomy failure, defined intraoperatively as an opening or dehiscence through the previous arthrotomy closure. T tests and chi-square analyses were used to determine differences between the suture cohorts, and bivariate logistic regression was used to determine associations with our 90-day reoperation outcomes.ResultsWith the numbers available, there was no association between suture type and 90-day all-cause reoperation (odds ratio [OR], 1.70; 95% CI, 0.82–3.53; p = 0.156). Suture type was not associated with wound-related reoperation (OR, 2.73; 95% CI, 0.97–7.69; p = 0.058). A 0.6% (five of 884) arthrotomy failure rate was observed in the barbed cohort while no (0 of 1598) arthrotomy failures were noted in the traditional group (p = 0.003). Deep infections were rare in both groups (two of 884 barbed sutures, 0 of 1598 standard sutures) and could not be compared.ConclusionsAlthough we saw no difference in overall and wound-related 90-day reoperation rates by suture type with the numbers available, we observed a higher frequency in our secondary question of arthrotomy failures when barbed sutures are used for arthrotomy closure during TKA. Given the widespread use of this closure technique, our preliminary pilot results warrant further investigation in larger multicenter cohorts.Level of EvidenceLevel III, therapeutic study.

Military Service and Decision Quality in the Management of Knee Osteoarthritis

Background Decision quality measures the degree to which care decisions are knowledge-based and value-aligned. Because military service emphasizes hierarchy, command, and mandates some healthcare decisions, military service may attenuate patient autonomy in healthcare decisions and lower decision quality. VA is the nations largest provider of orthopedic care. We compared decision quality in a sample of VA and non-VA patients seeking care for knee osteoarthritis. Methods Our study sample consisted of patients newly referred to our orthopedic clinic for the management of knee osteoarthritis. None of the study patients were exposed to a knee osteoarthritis decision aid. Consenting patients were administered the Hip/Knee Decision Quality Instrument (HK-DQI). In addition, they were surveyed about decision-making preferences and demographics. We compared results to a non-VA cohort from our academic institutions arthroplasty database. Results The HK-DQI Knowledge Score was lower in the VA cohort (45%, SD = 22, n = 25) compared with the non-VA cohort (53%, SD = 21, n = 177) (p = 0.04). The Concordance Score was lower in the VA cohort (36%, SD = 49%) compared with the control cohort (70%, SD 46%) (p = 0.003). Non-VA patients were more likely to make a high-quality decision (p = 0.05). Non-VA patients were more likely to favor a shared decision-making process (p = 0.002). Conclusions Decision quality is lower in Veterans with knee osteoarthritis compared with civilians, placing them at risk for lower treatment satisfaction and possibly unwarranted surgical utilization. Our future work will examine if this difference is from conditioned military service behaviors or confounding demographic factors, and if conventional shared decision-making techniques will correct this deficiency.

Resident Participation is Not Associated With Worse Outcomes After TKA

Background Approximately one-half of all US surgical procedures, and one-third of orthopaedic procedures, are performed at teaching hospitals. However, the effect of resident participation and their level of training on patient care for TKA postoperative physical function, operative time, length of stay, and facility discharge are unclear. Questions/purposes (1) Are resident participation, postgraduate year (PGY) training level, and number of residents associated with absolute postoperative Patient-Reported Outcomes Measurement Information System (PROMIS®-10) global physical function score (PCS), and achieving minimum clinically important difference (MCID) PCS improvement, after TKA? (2) Are resident participation, PGY, and number of residents associated with increased TKA operative time? (3) Are resident participation, PGY, and number of residents associated with increased length of stay after TKA? (4) Are resident participation, PGY, and number of residents associated with higher odds of patients being discharged to another inpatient facility, rather than to their home (facility discharge)? Methods We performed a retrospective study using a longitudinally maintained institutional registry of TKAs that included 1626 patients at a single tertiary academic institution from April 2011 through July 2016. All patients who underwent primary, elective unilateral TKA were included with no exclusions. All patients were included in the operative time, length of stay, and facility discharge models. The PCS model required postoperative PCS score (n = 1417; 87%; mean, 46.4; SD, 8.5) and the MCID PCS model required pre- and postoperative PCS (n = 1333; 82%; 55% achieved MCID). Resident participation was defined as named residents being present in the operating room and documented in the operative notes, and resident PGY level was determined by the date of TKA and its duration since the resident entered the program and using the standard resident academic calendar (July – June). Multivariable regression was used to assess PCS scores, operative time, length of stay, and facility discharge in patients whose surgery was performed with and without intraoperative resident participation, accounting for PGY training level and number of residents. We defined the MCID PCS score improvement as 5 points on a 100-point scale. Adjusting variables included surgeon, academic year, age, sex, race–ethnicity, Charlson Comorbidity Index, preoperative PCS, and patient-reported mental function, BMI, tobacco use, alcohol use, and postoperative PCS time for the PCS models. We had postoperative PCS for 1417 (87%) surgeries. Results Compared with attending-only TKAs (5% of procedures), no postgraduate year or number of residents was associated with either postoperative PCS or MCID PCS improvement (PCS: PGY-1 = -0.98, 95% CI, -6.14 to 4.17, p = 0.708; PGY-2 = -0.26, 95% CI, -2.01to 1.49, p = 0.768; PGY-3 = -0.32, 95% CI, -2.16 to 1.51, p = 0.730; PGY-4 = -0.28, 95% CI, -1.99 to 1.43, p = 0.746; PGY-5 = -0.47, 95% CI, -2.13 to 1.18, p = 0.575; two residents = 0.28, 95% CI, -1.05 to 1.62, p = 0.677) (MCID PCS: PGY-1 = odds ratio [OR], 0.30, 95% CI, 0.07–1.30, p = 0.108; PGY-2 = OR, 0.86, 95% CI, 0.46–1.62, p = 0.641; PGY-3 = OR, 0.97, 95% CI, 0.49–1.89, p = 0.921; PGY-4 = OR, 0.73, 95% CI, 0.39–1.36, p = 0.325; PGY-5 = OR, 0.71, 95% CI, 0.39–1.29, p = 0.259; two residents = OR, 1.23, 95% CI, 0.80–1.89, p = 0.337). Longer operative times were associated with all PGY levels except for PGY-5 (attending surgeon only [reference] = 85.60 minutes, SD, 14.5 minutes; PGY-1 = 100. 13 minutes, SD, 21.22 minutes, +8.44 minutes, p = 0.015; PGY-2 = 103.40 minutes, SD, 23.01 minutes, +11.63 minutes, p < 0.001; PGY-3 = 97.82 minutes, SD, 18.24 minutes, +9.68 minutes, p < 0.001; PGY-4 = 96.39 minutes, SD, 18.94 minutes, +4.19 minutes, p = 0.011; PGY-5 = 88.91 minutes, SD, 19.81 minutes, -0.29 minutes, p = 0.853) or the presence of multiple residents (+4.39 minutes, p = 0.024). There were no associations with length of stay (PGY-1 = +0.04 days, 95% CI, -0.63 to 0.71 days, p = 0.912; PGY-2 = -0.08 days, 95% CI, -0.48 to 0.33 days, p = 0.711; PGY-3 = -0.29 days, 95% CI, -0.66 to 0.09 days, p = 0.131; PGY-4 = -0.30 days, 95% CI, -0.69 to 0.08 days, p = 0.120; PGY-5 = -0.28 days, 95% CI, -0.66 to 0.10 days, p = 0.145; two residents = -0.12 days, 95% CI, -0.29 to 0.06 days, p = 0.196) or facility discharge (PGY-1 = OR, 1.03, 95% CI, 0.26–4.08, p = 0.970; PGY-2 = OR, 0.61, 95% CI, 0.31–1.20, p = 0.154; PGY-3 = OR, 0.98, 95% CI, 0.48–2.02, p = 0.964; PGY-4 = OR, 0.83, 95% CI, 0.43–1.57, p = 0.599; PGY-5 = OR, 0.7, 95% CI, 0.41–1.40, p = 0.372; two residents = OR, 0.93, 95% CI, 0.56–1.54, p = 0.766) for any PGY or number of residents. Conclusions Our findings should help assure patients, residents, physicians, insurers, and hospital administrators that resident participation, after adjusting for numerous patient and clinical factors, does not have any association with key medical and financial metrics, including postoperative PCS, MCID PCS, length of stay, and facility discharge. Future research in this field should focus on whether residents affect knee-specific patient-reported outcomes such as the Knee Injury and Osteoarthritis Score and additional orthopaedic procedures, and determine how resident medical education can be further enhanced without compromising patient care and safety. Level of Evidence Level III, therapeutic study.

The Effect of Absorbable Calcium Sulfate on Wear Rates in Ultra-high–Molecular-weight Polyethylene: Potential Implications for Its Use in Treating Arthroplasty Infections

Introduction: Patients, hospitals, and healthcare systems incur substantial burdens when infections result in total joint revisions. One potential solution to mitigate some of these burdens may be to transition from a two-stage infection treatment to a single-stage procedure. Off-label use of an absorbable calcium sulfate antibiotic carrier has been implemented in single-stage and two-stage procedures globally, with the goal of moving toward more single-stage revisions in the United States. Adverse effects of calcium sulfate on the joint space during articulation are currently unknown. Methods: This study aims to determine the impact of calcium sulfate beads on wear of polyethylene during and following exposure. Two phases of in vitro pin-on-disk testing were conducted. The first phase exposed polyethylene pins to calcium sulfate for 500,000 cycles of a 2-million cycle test. The second phase examined the wear of pins that were created from retrieved components exposed to calcium sulfate in vivo. Results: No clinically significant difference was observed between the wear rates of the calcium sulfate–exposed polyethylene pins and the control polyethylene pins. Discussion: Preliminary results suggest that a substantial increase in the wear rate of polyethylene is not expected with the addition of calcium sulfate beads during treatment of infection.