Ifeoma A. Inneh

Management of Modifiable Risk Factors Prior to Primary Hip and Knee Arthroplasty: A Readmission Risk Assessment Tool.

BACKGROUND Preoperative risk stratification and optimization of preoperative care may be helpful in reducing readmission rates after primary total joint arthroplasty. Assessment of the predictive value of individual modifiable risk factors without a tool to assess cumulative risk may not provide proper risk stratification of patients with regard to potential readmissions. As part of a Perioperative Orthopaedic Surgical Home model, we developed a scoring system, the Readmission Risk Assessment Tool (RRAT), which allows for risk stratification in patients undergoing elective primary total joint arthroplasty at our institution. The purpose of this study was to analyze the relationship between the RRAT score and readmission after primary hip or knee arthroplasty. METHODS The RRAT, which is scored incrementally on the basis of the number and severity of modifiable comorbidities, was used to generate readmission scores for a cohort of 207 readmitted patients and two cohorts (one random and one age-matched) of 234 non-readmitted patients each. Regression analysis was performed to assess the strength of association of individual risk factors and the RRAT score with readmissions. We also calculated the odds and odds ratio (OR) at each RRAT score level to identify patients with relatively higher risk of readmission. RESULTS There were 207 (2.08%) readmissions among 9930 patients over a six-year period (2008 through 2013). Surgical site infection was the most common cause of readmission (ninety-three cases, 45%). The median RRAT scores were 3 (IQR [interquartile range], 1 to 4) and 1 (IQR, 0 to 2) for readmitted and non-readmitted groups, respectively. An RRAT score of ≥3 was significantly associated with higher odds of readmission. CONCLUSIONS Population health management, cost-effective care, and optimization of outcomes to maximize value are the new maxims for health-care delivery in the United States. We found that the RRAT score had a significant association with readmission after joint arthroplasty and could potentially be a clinically useful tool for risk mitigation.

Risk Factors for Infection Following Total Knee Arthroplasty: A Series of 3836 Cases from One Institution

Higher PJI rates may be related to identifiable risk factors, which may or may not be modifiable. Identifying risk factors preoperatively provides opportunities for modification and potentially decreasing the incidence of PJI. The purposes of this study were to: (1) retrospectively identify and quantify risk factors for PJI following primary TKA, and (2) to classify those significant risk factors as either non-modifiable or modifiable for intervention prior to surgery. Optimization of modifiable risk factors such as Staphylococcus aureus colonization, and tobacco use prior to primary TKA may decrease the incidence of periprosthetic joint infection after primary TKA, thereby reducing morbidity and the costs associated with treating those infections.

Focused Risk Analysis: Regression Model Based on 5,314 Total Hip and Knee Arthroplasty Patients from a Single Institution

We aimed to identify significant demographic, preoperative comorbidity and surgical predictors for major complications for use in the development of a risk prediction tool for a well-defined population as Total Joint Arthroplasty (TJA) patients. Data on 5314 consecutive patients who underwent primary total hip or knee arthroplasty from October 1, 2008 through September 30, 2011 at a single institution were used in a multivariate regression analysis. The overall incidence of a primary endpoint (reoperation during same admission, extended length of stay, and 30-day readmission) was 3.8%. Significant predictors include certain preexisting genitourinary, circulatory and respiratory conditions; ASA>2; advanced age and prolonged operating time. Mental health conditions demonstrate a strong predictive effect for subsequent serious complication(s) in TJA patients and should be included in a risk-adjustment tool.

Evaluation of the first-generation AAOS clinical guidelines on the prophylaxis of venous thromboembolic events in patients undergoing total joint arthroplasty: experience with 3289 patients from a single institution.

BACKGROUND Patients undergoing total hip or total knee arthroplasty have risks that include venous thromboembolism. The American Academy of Orthopaedic Surgeons has promulgated guidelines for the preoperative assessment of patients with the primary objective of preventing pulmonary embolism. We aimed to evaluate and establish the utility of the first-generation American Academy of Orthopaedic Surgeons guidelines for the prophylaxis of venous thromboembolism in patients undergoing total joint arthroplasty at a single institution. METHODS A prospective analysis of 3289 consecutive patients managed with total hip or total knee arthroplasty at the Connecticut Joint Replacement Institute between June 1, 2009, and April 30, 2011, was conducted. Data on age, sex, body mass index, American Society of Anesthesiologists classification, and a personal or family history of blood clots requiring long-term warfarin use were analyzed, as were data on a personal history of a malignant tumor, a bleeding disorder, gastrointestinal bleeding, or a hemorrhagic cerebrovascular accident. All patients were managed prophylactically with a specific algorithm based on the American Academy of Orthopaedic Surgeons guidelines. All of the patients were mobilized on postoperative day one, and pneumatic foot-pump compression was used for the duration of the hospitalization. RESULTS Thirty-six major venous thromboembolic events were documented with Doppler ultrasound or computed tomography angiography, for a ninety-day incidence of 1.1% (95% confidence interval, 0.8% to 1.5%). A personal history of blood clots was significantly associated with a blood clot in the proximal part of the thigh or a pulmonary embolism, but a family history of blood clots and a personal history of a malignant tumor did not show a significant relationship with venous thromboembolism. The ninety-day incidence of venous thromboembolism was significantly different between total hip arthroplasty patients (0.56%; 95% confidence interval, 0.30% to 1.15%) and total knee arthroplasty patients (1.46%; 95% confidence interval, 1.01% to 2.10%). The risk was greater in high-risk total knee arthroplasty patients compared with high-risk total hip arthroplasty patients despite comparable prophylaxis with enoxaparin sodium for twenty-eight days. CONCLUSIONS The prospective use of the first-generation American Academy of Orthopaedic Surgeons guidelines resulted in a low incidence of clinically important thromboembolic events in total hip and total knee arthroplasty patients. When properly used in these patients, the guidelines to minimize adverse outcomes are executable and effective. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Role of Sociodemographic, Co-morbid and Intraoperative Factors in Length of Stay Following Primary Total Hip Arthroplasty

We aimed to examine and quantify the combined association of patient sociodemographic, preoperative comorbidities and intraoperative factors with extended and prolonged length of stay (LOS) following primary total hip arthroplasty. Longer LOS was associated with Age (≥65 years), BMI ≥30 kg/m(2), ASA score >2, minority race/ethnicity, low SES, general anesthesia, comorbidities of the Circulatory, Genitourinary and Respiratory systems, and operating time. Collectively, being of low SES, advanced age (≥65 years) and minority race/ethnicity was most significantly associated with prolonged LOS (>7 days). The combined associations of lower SES, female gender, advanced age, non-Caucasian race/ethnicity and certain comorbidities presented a synergistically elevated risk for longer LOS and may warrant the need to consider sociodemographic status when allocating resources to hospitals serving such patients.

The Combined Influence of Sociodemographic, Preoperative Comorbid and Intraoperative Factors on Longer Length of Stay After Elective Primary Total Knee Arthroplasty

This study assessed the collective association of sociodemographic, preoperative comorbid and intraoperative factors with longer length of stay (LOS) following elective primary total knee arthroplasty. Sociodemographic characteristics examined on 2638 adult cases included age, race/ethnicity, gender and socioeconomic status (SES). Intraoperative factors included operating time and anesthesia type. The collective associations of lower SES, female gender, advanced age, non-Caucasian race/ethnicity and certain comorbidities do present a synergistically elevated risk for longer LOS. In a value-driven healthcare environment, these findings further warrant the need for policymakers and payers to consider sociodemographic status when allocating resources to hospitals serving such patients.

Effect of Tranexamic Acid on Transfusion Rates Following Total Joint Arthroplasty: A Cost and Comparative Effectiveness Analysis

Tranexamic acid (TXA) is used to reduce blood loss in orthopedic total joint arthroplasty (TJA). This study evaluates the effectiveness of TXA in reducing transfusions and hospital cost in TJA. Participants undergoing elective TJA were stratified into 2 cohorts: those not receiving and those receiving intravenous TXA. TXA decreased total hip arthroplasty (THA) transfusions from 22.7% to 11.9%, and total knee arthroplasty (TKA) from 19.4% to 7.0%. The average direct hospital cost reduction for THA and TKA was

Can a Hip and Knee Adult Reconstruction Orthopaedic Surgeon Sustain a Practice Comprised Entirely of Medicare Patients

3083 and

The Present and Future of Genomics in Adult Reconstructive Orthopaedic Surgery

2582, respectively. Implementation of a TJA TXA protocol significantly reduced transfusions in a safe and cost-effective manner.

Early Results of Medicare's Bundled Payment Initiative for a 90-Day Total Joint Arthroplasty Episode of Care.

Reimbursement continues to decrease for orthopaedic surgeons specializing in total joint arthroplasty (TJA). Practice information from the Medical Group Management Association (MGMA) Cost Survey and Private practice Compensation Survey and CMS locality reimbursement data was used to develop a practice model for a TJA specialist performing 300 TJA per year (66% knees, 33% hips, 15% revision surgery), evaluating 3000 outpatient visits per year based on, current Medicare reimbursement rates. Our model shows that the anticipated physician compensation is well below the mean compensation reported for a TJA specialist irrespective of geographic location. When MGMA practice expense data are applied to the Medicare-only model, the salary level is unsustainable. Further decreases in Medicare Part B reimbursement will only worsen the disparity.