Melanie C. Besculides

National trends in anterior cervical fusion procedures.

Study Design. Population-based database analysis. Objective. To analyze trends in patient- and healthcare-system-related characteristics, utilization and outcomes associated with anterior cervical spine fusions. Summary of Background Data. Anterior cervical decompression and spine fusion (ACDF) is one of the most commonly performed surgical procedures of the spine. However, few data analyzing trends in patient- and healthcare-system-related characteristics, utilization and outcomes exist. Methods. Data from 1990 to 2004 collected in the National Hospital Discharge Survey were accessed. ACDF procedures were identified. Five-year periods of interest (POI) were created for temporal analysis and changes in the prevalence and utilization of this procedure as well as in patient- and healthcare-system-related variables were examined. The changes in the occurrence of procedure-related complications were evaluated. Results. An estimated total of 771,932 discharges after ACDF were identified. Temporally, an almost 8-fold increase in total prevalence was accompanied by a similar increase in utilization (23/100.000 civilians/POI to 157/100.000/civilians/POI). The highest increase in utilization was observed in those ≥65 years (28-fold). Average age increased from 47.2 years to 50.5 years over time. Length of hospital stay decreased from 5.17 days to 2.38 days. Overall procedure-related complication rates decreased from 4.6% to 3.03%. The prevalence of hypertension, diabetes mellitus, hypercholesterolemia, obesity, pulmonary, and coronary artery increased over time among patients undergoing ACDF. Conclusion. Despite limitations inherent to secondary analysis of large databases, we identified a number of significant changes in the utilization, demographics, and outcomes associated with ACDF, which can be used to assess the effect of changes in medical care, direct health care resources, and future research. The effect of the increased prevalence of comorbidities on medical practice remains to be evaluated. Further studies are necessary to evaluate causal relationships.

What Do We Know About the Link Between Marriage and Health

This special journal issue presents nine new studies on the relationship between marriage and health among African Americans. It discusses health disparities between African Americans and other racial and ethnic groups, offers an overview of African American marriage rates, and presents evidence for the marriage-health link in this population.

Trends in Demographics, Comorbidity Profiles, In-Hospital Complications and Mortality Associated With Primary Knee Arthroplasty

We analyzed the National Hospital Discharge Survey to elucidate temporal changes in the demographics, comorbidities, hospital stay, in-hospital complications, and mortality of patients undergoing primary total knee arthroplasties (TKAs) in the United States. Three 5-year periods were created (1990-1994, 1995-1999, and 2000-2004), and temporal changes were analyzed. The number of TKAs performed increased by 125% for the 3 periods. The increasing proportion of younger patients was accompanied by a concomitant decrease of Medicare-insured patients. Length of stay decreased from 8.44 to 4.18 days. An increase in the proportion of discharges to long-term and short-term care facilities and in procedures performed in small hospitals was noted. Although the prevalence of procedure-related complications decreased over time, comorbidities increased. Despite a decrease in mortality from the first to the second study period (0.50% vs 0.21%), a slight increase was noticed more recently (0.28%). We identified significant changes in most variables studied.

Risk factors for perioperative mortality after lower extremity arthroplasty: a population-based study of 6,901,324 patient discharges.

The goal of this study was to provide nationally representative data on characteristics of patients who died after hip and knee arthroplasty and to determine risk factors for such outcome. Using national in-patient data collected between 1990 and 2004, we identified a cumulative in-hospital mortality rate of 0.35% among an estimated 6,901,324 procedures. The strongest independent risk factors for in-hospital mortality were pulmonary embolism and cerebrovascular complications, which increased the odds for a fatal outcome by approximately 40-fold. Preoperative risk factors for in-hospital mortality were revision total hip arthroplasty, advanced age, and the presence of a number of comorbid diseases, predominantly dementia, renal, and cerebrovascular disease. Our results can be used to identify patients at risk for fatal outcome and implement interventions to reduce such risk.

A Rude Awakening — The Perioperative Sleep Apnea Epidemic

Obstructive sleep apnea may increase the risk of perioperative complications and is more prevalent among candidates for surgery than in the general population. With more than 40 million surgical procedures performed annually, the costs are high.

Perioperative comparative effectiveness research

The goal of comparative effectiveness research (CER) is to improve effectiveness, efficacy and efficiency in health care. While CER seems to present a major opportunity to introduce accountability into health care by identifying and promoting best practices in medicine, many issues surrounding CER remain poorly understood by clinicians and researchers, including what study designs are most appropriate for such research and what analytic tools are most helpful. The goal of this review is therefore to provide background and definitions of what constitutes CER and to discuss the various study designs and their strengths and weaknesses in achieving the stated goals of CER, while relating them to examples relevant to perioperative research. We provide a brief outline of the types of analytic methods particularly useful for CER and connect the reader to references for their practice. Finally, we assess the role of CER in perioperative research and provide some thoughts on future paths.

Successful Strategies for Educating Hard-to-Reach Populations: Lessons Learned from Massachusetts' Train-the-Trainer Project Using the "Helping You Take Care of Yourself" Curriculum.

Objective: To assess the effectiveness of providing education on breast, cervical and cardiovascular health to hard-to-reach women throughout Massachusetts using an innovative derivation of the ‘train-the-trainer’ approach. Innovation included use of contracts with community-based organizations (CBOs) that required data collection in return for payment. Design: Quantitative and qualitative evaluation. Setting: Hard-to-reach women throughout Massachusetts. Methods: Contracted with CBOs to conduct educational sessions on breast, cervical, and cardiovascular health using a standardized curriculum. Collected and analyzed quantitative data from 2,526 women educated by CBOs to assess the programme’s reach and effectiveness. Interviewed staff involved in programme implementation and conducted focus groups with women educated to identify programme successes and areas for improvement. Results: Thirty-three unique CBOs conducted 264 educational sessions, educating 2,526 women in one or more units (breast, cervical, or cardiovascular health) of the Helping You Take Care of Yourself curriculum. Quantitative data were obtained to assess programme effectiveness and the curriculum successfully increased knowledge for all health units. Qualitative evaluation identified several factors that contributed to the success of the programme, including: establishing relationships with CBOs that had existing ties in target communities; executing memoranda of understanding that required data collection for payment; developing curriculum toolkits and intensive staff training; and delivering education in small group settings. Conclusion: The innovative structure of implementation of a ‘train-the-trainer’ approach allowed for expanded reach of the health education curriculum, educating more than 2,000 hard-to-reach women. The strategies employed can be applied to other health education programmes.