Nitin B. Jain

The Relationship Between Surgeon and Hospital Volume and Outcomes for Shoulder Arthroplasty

BACKGROUND As far as we know, no previous study has determined the relationship between volume and outcomes for shoulder arthroplasty. We hypothesized that surgeons and hospitals with higher caseloads of total shoulder arthroplasties and hemiarthroplasties have better outcomes as measured by decreased mortality rate, shorter length of stay in the hospital, reduced postoperative complications, and routine disposition of patients on discharge. METHODS Data on patients undergoing shoulder arthroplasty were extracted from the Nationwide Inpatient Sample databases for the years 1988 through 2000. Logistic regression with generalized estimating equations and multiple linear regression models were used to estimate the adjusted association between surgeon and hospital volume and outcomes for total shoulder arthroplasty and hemiarthroplasty after adjusting for comorbidity, age, race, household income, and sex. RESULTS The mortality rates for patients who had a total shoulder arthroplasty performed by surgeons who did fewer than two procedures per year (0.36%) or who did between two and fewer than four procedures per year (0.32%) were higher than those for patients who had a total shoulder arthroplasty performed by surgeons who did four procedures or more per year (0.20%). The risk-adjusted rate of postoperative complications after hemiarthroplasty was significantly higher for patients managed by surgeons who performed fewer than two procedures per year (1.68%) than for those managed by surgeons with a volume of five procedures or more per year (0.97%). The possibility of postoperative complications when total shoulder arthroplasty was performed in hospitals with a volume of fewer than five procedures (1.44%) or in those with a volume of five to ten procedures per year (1.45%) was significantly higher than that in hospitals where ten procedures or more were performed every year (0.64%). The mean lengths of stay in the hospital after total shoulder arthroplasty and hemiarthroplasty were significantly longer when the operations were performed by surgeons who did fewer than two procedures per year or when they were done in hospitals with a volume of fewer than five procedures per year or with a volume of five to fewer than ten procedures per year than when they were done in hospitals or by surgeons in the highest volume category (p < 0.001). CONCLUSIONS Patients who have a total shoulder arthroplasty or hemiarthroplasty performed by a high-volume surgeon or in a high-volume hospital are more likely to have a better outcome. LEVEL OF EVIDENCE Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Comorbidities increase complication rates in patients having arthroplasty

The objective of our study was to assess the effect of comorbidities (hypertension, diabetes, obesity, and their combinations) on postoperative complications and discharge status in patients having shoulder, hip, and knee arthroplasty (n = 959,839). The association between outcomes and each of the comorbidities was assessed using multivariable logistic regression after adjusting for age, race, household income, gender, and hospital volume. In the multivariable models, postoperative complications were more likely in patients with hypertension, diabetes, or obesity as compared with patients without these comorbidities (for hypertension, odds ratio = 1.07; 95% confidence interval range, 1.04-1.11; for obesity, odds ratio = 1.3; 95% confidence interval range, 1.22-1.41). The likelihood of a nonhomebound disposition of patients on discharge was 1.30 times (95% confidence interval range, 1.27-1.32) in patients with diabetes and 1.45 times (95% confidence interval range, 1.40-1.49) in patients who were obese as compared with patients without these respective comorbidities. Patients with a combination of comorbidities also had a higher likelihood of postoperative complications and nonhomebound discharge. Results of our study showed that hypertension, diabetes, and obesity are independent predictors of increased postoperative complications and non-homebound discharge in patients undergoing shoulder, hip, or knee arthroplasty. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

A Prospective Study of Bone Lead Concentration and Death From All Causes, Cardiovascular Diseases, and Cancer in the Department of Veterans Affairs Normative Aging Study

Background— Blood lead concentration has been associated with mortality from different causes in several studies. Many effects of lead exposure that might increase risk of death are likely to result from cumulative exposure, for which bone lead is a better biomarker than blood lead. The association between bone lead levels and mortality has not been explored. Methods and Results— We prospectively assessed the association between both blood lead and bone lead, analyzed with the use of K-shell x-ray fluorescence, and mortality among 868 men in the Normative Aging Study. We identified 241 deaths over an average of 8.9 (SD=3.9) years of follow-up. We calculated adjusted hazard ratios and 95% confidence intervals using Cox proportional hazards. Compared with the lowest tertile of patella bone lead, the fully adjusted hazard ratios in the highest tertile for all-cause, cardiovascular (n=137 deaths), and ischemic heart disease (n=62 deaths) mortality were 1.25 (95% confidence interval, 0.82 to 1.92), 1.42 (95% confidence interval, 0.80 to 2.51), and 1.87 (95% confidence interval, 0.77 to 4.53), respectively. Results were similar for tibia lead. Bone lead was not associated with cancer, and blood lead was not associated with any mortality category. Conclusions— We found bone lead to be associated with a slight increase in all-cause and cardiovascular mortality in an environmentally exposed population with low blood lead levels, but this did not reach statistical significance. This study suggests that cumulative lead exposure from prior decades of high environmental exposures may affect risk of death despite recent declines in environmental lead exposure, but studies with more follow-up are needed.

High Hospital Volume Is Associated with Better Outcomes for Breast Cancer Surgery: Analysis of 233,247 Patients

Background:The relationship between hospital volume and outcomes needs to be further elucidated for low-risk procedures such as surgical therapy of localized breast cancer. The objective of this investigation was to assess the relationship between hospital volume and outcomes for breast cancer surgery.Methods: A total of 233,247 patients who underwent breast-conserving therapy (BCT) and breast-ablative therapy (BAT) for localized breast cancer were extracted from 13 years (1988–2000) of the Nationwide Inpatient Samples. Hospital volume was classified as low (<30 cases/year), intermediate (≥ 30 to <70cases/year), and high (≥ 70 cases/year). Multiple linear and logistic regression analyses were used to assess the risk-adjusted association between hospital volume and outcomes.Results: In risk-adjusted analyses, patients operated on at low-volume hospitals were 3.04 (p = 0.03) times more likely to die after BCT compared with patients operated on at high-volume hospitals. Similarly, low-volume hospitals had a significantly higher likelihood of postoperative complications (odds ratio [OR] = 1.73, p = 0.01 for BCT; OR = 1.44, p < 0.001 for BAT) compared with high-volume hospitals. Compared with low-volume hospitals, length of hospital stay was significantly shorter and nonroutine patient discharge significantly lower for high-volume providers for both BCT and BAT (all p < 0.001). Patients were also significantly less likely to undergo BCT if operated on in a low- or intermediate-volume hospital compared with a high-volume provider (p < 0.001).Conclusions: High-volume hospitals had significantly lower nonroutine patient discharge, postoperative morbidity and mortality, shorter length of hospital stay, and higher likelihood of performing BCT. Referral of patients with localized breast cancer to high-volume hospitals may be justified.

Lead Levels and Ischemic Heart Disease in a Prospective Study of Middle-Aged and Elderly Men: the VA Normative Aging Study

Background Lead exposure has been associated with higher blood pressure, hypertension, electrocardiogram abnormalities, and increased mortality from circulatory causes. Objective We assessed the association between bone lead—a more accurate biomarker of chronic lead exposure than blood lead—and risk for future ischemic heart disease (IHD). Methods In a prospective cohort study (VA Normative Aging Study), 837 men who underwent blood or bone lead measurements at baseline were followed-up for an ischemic heart disease event between 1 September 1991 and 31 December 2001. IHD was defined as either a diagnosis of myocardial infarction or angina pectoris that was confirmed by a cardiologist. Events of fatal myocardial infarction were assessed from death certificates. Results An IHD event occurred in 83 cases (70 nonfatal and 13 fatal). The mean blood, tibia, and patella lead levels were higher in IHD cases than in noncases. In multivariate Cox-proportional hazards models, one standard deviation increase in blood lead level was associated with a 1.27 (95% confidence interval, 1.01–1.59) fold greater risk for ischemic heart disease. Similarly, a one standard deviation increase in patella and tibia lead levels was associated with greater risk for IHD (hazard ratio for patella lead = 1.29; 95% confidence interval, 1.02–1.62). Conclusions Men with increased blood and bone lead levels were at increased risk for future IHD. Although the pathogenesis of IHD is multifactorial, lead exposure may be one of the risk factors.

Factors Associated with Health-Related Quality of Life in Chronic Spinal Cord Injury

Jain NB, Sullivan M, Kazis LE, Tun CG, Garshick E: Factors associated with health-related quality of life in chronic spinal cord injury. Am J Phys Med Rehabil 2007;86:387–396. Objective:An important goal of rehabilitation and treatment after spinal cord injury (SCI) is to improve function and enhance health-related quality of life (HRQoL). However, previous assessments are limited by use of HRQoL instruments not specific to SCI. Although respiratory dysfunction is common in SCI, it has not been possible to assess the association of comorbid medical conditions, including respiratory symptoms and pulmonary function, to HRQoL. Therefore, we assessed whether these factors were associated with HRQoL in SCI using an SCI-specific HRQoL questionnaire. Design:In our cross-sectional study, 356 participants ≥1 yr post-SCI completed a 23-item SCI-specific HRQoL questionnaire and a detailed health questionnaire, and underwent pulmonary function testing and a neurological exam at VA Boston between 1998 and June 2003. Results:In a multivariate regression model, age, employment status, motor level and completeness of injury, and ambulatory mode (use of hand-propelled or motorized wheelchair, use of crutches or canes, or walking independently) were independently associated with HRQoL. After adjusting for these factors, chronic cough, chronic phlegm, persistent wheeze, dyspnea with activities of daily living, and lower forced expiratory volume in 1 sec and forced vital capacity were each associated with a lower HRQoL. Conclusions:These results provide evidence for the clinical validity of our SCI-specific HRQoL instrument. We also identify potentially modifiable factors that, if addressed, may lead to HRQoL improvement in SCI.

Childhood correlates of blood lead levels in Mumbai and Delhi.

Background Lead exposure has previously been associated with intellectual impairment in children in a number of international studies. In India, it has been reported that nearly half of the children have elevated blood lead levels (BLLs). However, little is known about risk factors for these elevated BLLs. Methods We conducted a retrospective cross-sectional analysis of data from the Indian National Family Health Survey, a population-based study conducted in 1998–1999. We assessed potential correlates of BLLs in 1,081 children who were < 3 years of age and living in Mumbai or Delhi, India. We examined factors such as age, sex, religion, caste, mother’s education, standard of living, breast-feeding, and weight/height percentile. Results Most children (76%) had BLLs between 5 and 20 μg/dL. Age, standard of living, weight/height percentile, and total number of children ever born to the mother were significantly associated with BLLs (log transformed) in multivariate regression models. Compared with children ≤3 months of age, children 4–11 and 12–23 month of age had 84 and 146% higher BLLs, respectively (p < 0.001). A low standard of living correlated with a 32.3% increase in BLLs (p = 0.02). Children greater than the 95th percentile for their weight/height had 31% (p = 0.03) higher BLLs compared with those who were below the 5th percentile for their weight/height. Conclusions Our study found various factors correlated with elevated BLLs in children. The correlation between greater than the 95th percentile weight/height and higher BLL may reflect an impact of lead exposure on body habitus. Our study may help in targeting susceptible populations and identifying correctable factors for elevated BLLs in Mumbai and Delhi.

Association of Shoulder Pain With the Use of Mobility Devices in Persons With Chronic Spinal Cord Injury

To assess the prevalence of shoulder pain and its association with the use of assistive devices for mobility in persons with chronic spinal cord injury (SCI).

Association Between Mobility Mode and C-Reactive Protein Levels in Men With Chronic Spinal Cord Injury

OBJECTIVE To assess clinical determinants of systemic inflammation in persons with chronic spinal cord injury (SCI). DESIGN Cross-sectional survey. SETTING Veterans Affairs medical center. PARTICIPANTS As part of an epidemiologic study assessing SCI-related health conditions, 63 men with chronic SCI provided a blood sample and information regarding locomotive mode and personal habits. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Plasma high-sensitivity C-reactive protein (CRP). RESULTS The mean +/- standard deviation age was 56+/-14y, and participants were assessed 21+/-13y after injury. Adjusting for heart disease, hypertension, and body mass index (BMI), the mean CRP in 12 motorized wheelchair users (5.11mg/L) was not significantly greater than 23 participants who used a manual wheelchair (2.19mg/L) (P=.085) but was significantly greater than the 17 who walked with an assistive device (1.41mg/L) (P=.005) and the 12 who walked independently (1.63mg/L) (P=.027). CRP was significantly greater in participants with obesity but was not related to age, smoking, or SCI level and severity. CRP was elevated in participants reporting a urinary tract infection (UTI) or pressure ulcer within a year, but adjustment for this did not account for the elevated CRP in motorized wheelchair users. CONCLUSIONS These results suggest that CRP in chronic SCI is independently related to locomotive mode, BMI, and a history of pressure ulcers and UTI. It is suggested that future studies in SCI investigate whether modifying these factors influence systemic inflammation and cardiovascular health.

The contribution of reverse shoulder arthroplasty to utilization of primary shoulder arthroplasty

BACKGROUND We assessed the contribution of reverse shoulder arthroplasty to overall utilization of primary shoulder arthroplasty and present age- and sex-stratified national rates of shoulder arthroplasty. We also assessed contemporary complication rates, mortality rates, and indications for shoulder arthroplasty, as well as estimates and indications for revision arthroplasty. METHODS We used the Nationwide Inpatient Samples for 2009 through 2011 to calculate estimates of shoulder arthroplasty and assessed trends using Joinpoint (National Cancer Institute, Bethesda, MD) regression. RESULTS The cumulative estimated utilization of primary shoulder arthroplasty (anatomic total shoulder arthroplasty, hemiarthroplasty, and reverse shoulder arthroplasty) increased significantly from 52,397 procedures (95% confidence interval [CI], 47,093-57,701) in 2009 to 67,184 cases (95% CI, 60,638-73,731) in 2011. Reverse shoulder arthroplasty accounted for 42% of all primary shoulder arthroplasty procedures in 2011. The concomitant diagnosis of osteoarthritis and rotator cuff impairment was found in only 29.8% of reverse shoulder arthroplasty cases. The highest rate of reverse shoulder arthroplasty was in the 75- to 84-year-old female subgroup (77 per 100,000 persons; 95% CI, 67-87). Revision cases comprised 8.8% and 8.2% of all shoulder arthroplasties in 2009 and 2011, respectively, and 35% of revision cases were because of mechanical complications/loosening whereas 18% were because of dislocation. CONCLUSIONS The utilization of primary shoulder arthroplasty significantly increased in just a 3-year time span, with a major contribution from reverse shoulder arthroplasty in 2011. Indications appear to have expanded because a large percentage of patients did not have rotator cuff pathology. The burden from revision arthroplasties was also substantial, and efforts to optimize outcomes and longevity of primary shoulder arthroplasty are needed.