Peter Cram

Clinical characteristics and outcomes of Medicare patients undergoing total hip arthroplasty, 1991-2008.

CONTEXT Total hip arthroplasty is a common surgical procedure but little is known about longitudinal trends. OBJECTIVE To examine demographics and outcomes of patients undergoing primary and revision total hip arthroplasty. DESIGN, SETTING, AND PARTICIPANTS Observational cohort of 1,453,493 Medicare Part A beneficiaries who underwent primary total hip arthroplasty and 348,596 who underwent revision total hip arthroplasty. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes for primary and revision total hip arthroplasty between 1991 and 2008. MAIN OUTCOME MEASURES Changes in patient demographics and comorbidity, hospital length of stay (LOS), mortality, discharge disposition, and all-cause readmission rates. RESULTS Between 1991 and 2008, the mean age for patients undergoing primary total hip arthroplasty increased from 74.1 to 75.1 years and for revision total hip arthroplasty from 75.8 to 77.3 years (P < .001). The mean number of comorbid illnesses per patient increased from 1.0 to 2.0 for primary total hip arthroplasty and 1.1 to 2.3 for revision (P < .001). For primary total hip arthroplasty, mean hospital LOS decreased from 9.1 days in 1991-1992 to 3.7 days in 2007-2008 (P = .002); unadjusted in-hospital and 30-day mortality decreased from 0.5% to 0.2% and from 0.7% to 0.4%, respectively (P < .001). The proportion of primary total hip arthroplasty patients discharged home declined from 68.0% to 48.2%; the proportion discharged to skilled care increased from 17.8% to 34.3%; and 30-day all-cause readmission increased from 5.9% to 8.5% (P < .001). For revision total hip arthroplasty, similar trends were observed in hospital LOS, in-hospital mortality, discharge disposition, and hospital readmission rates. CONCLUSION Among Medicare beneficiaries who underwent primary and revision hip arthroplasty between 1991 and 2008, there was a decrease in hospital LOS but an increase in the rates of discharge to postacute care and readmission.

Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: analysis from the ACS-NSQIP.

Recently, the government has moved towards public reporting of 30-day readmission rates after elective primary total knee (TKA) and total hip arthroplasty (THA). We identified 11,814 and 8105 patients who underwent primary TKA and THA from the 2011 ACS NSQIP. Overall readmission rates within 30-days of surgery were 4.6% for TKA and 4.2% for THA. Complications associated with readmission were predominantly wound infections, sepsis, thromboembolic, cardiac, and respiratory related. In TKA, multivariate analysis identified age (P=0.002), male gender (P=0.03), cancer history (P=0.008), elevated BUN (P=0.002), a bleeding disorder (P<0.001) and high ASA class (P<0.001) as predictors of readmission. In THA, obesity (P=0.008), steroid use (P=0.037), a bleeding disorder (P=0.002), dependent functional status (P=0.022), and high ASA class (P<0.001) predicted readmission. Understanding characteristics associated with readmission will be essential for equitable patient risk stratification.

Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis

BACKGROUND Although remote intensive care unit (ICU) coverage is rapidly being adopted to enhance access to intensivists, its effect on patient outcomes is unclear. We conducted a meta-analysis to examine the impact of telemedicine ICU (tele-ICU) coverage on mortality and length of stay (LOS). METHODS We conducted a systematic review of studies published from January 1, 1950, through September 30, 2010, using PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Global Health, Web of Science, the Cochrane Library, and conference abstracts. We included studies that reported data on the primary outcomes of ICU and in-hospital mortality or on the secondary outcomes of ICU and hospital LOS. RESULTS We identified 13 eligible studies involving 35 ICUs. All the studies used a before-and-after design. The studies included 41 374 patients (15 667 pre-tele-ICU and 25 707 post-tele-ICU patients). Tele-ICU coverage was associated with a reduction in ICU mortality (pooled odds ratio, 0.80; 95% confidence interval [CI], 0.66-0.97; P = .02) but not in-hospital mortality for patients admitted to an ICU (pooled odds ratio, 0.82; 95% CI, 0.65-1.03; P = .08). Similarly, tele-ICU coverage was associated with a reduction in ICU LOS (mean difference, -1.26 days; 95% CI, -2.21 to -0.30; P = .01) but not hospital LOS (mean difference, -0.64; 95% CI, -1.52 to 0.25; P = .16). CONCLUSION Tele-ICU coverage is associated with lower ICU mortality and LOS but not with lower in-hospital mortality or hospital LOS.

Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national medicare data

Objective To examine whether racial disparities in usage and outcomes of total knee and total hip arthroplasty (TKA and THA) have declined over time. Methods We used data from the US Medicare Program (MedPAR data) for years 1991–2008 to identify four separate cohorts of patients (primary TKA, revision TKA, primary THA, revision THA). For each cohort, we calculated standardised arthroplasty usage rates for Caucasian and African–American Medicare beneficiaries for each calendar year, and examined changes in disparities over time. We examined unadjusted and adjusted outcomes (30-day readmission rate, discharge disposition etc.) for Caucasians and African–Americans, and whether disparities decreased over time. Results In 1991, the use of primary TKA was 36% lower for African–Americans compared with Caucasians (20.6 per 10 000 for African–Americans; 32.1 per 10 000 for Caucasians; p<0.0001); in 2008, usage of primary TKA was 40% lower for African–Americans (41.5 per 10 000 for African–Americans; 68.8 per 10 000 for Caucasians; p<0.0001) with similar findings for the other cohorts. Black–White disparities in 30-day hospital readmission increased significantly from 1991–2008 among three patient cohorts. For example in 1991 30-day readmission rates for African–Americans receiving primary TKA were 6% higher than for Caucasians; by 2008 readmission rates for African–Americans were 24% higher (p<0.05 for change in disparity). Similarly, black–white disparities in the proportion of patients discharged to home after surgery increased across the study period for all cohorts (p<0.05). Conclusions In an 18-year analysis of US Medicare data, we found little evidence of declines in racial disparities for joint arthroplasty usage or outcomes.

Adverse Outcomes in Hip Arthroplasty: Long-Term Trends

BACKGROUND Total hip arthroplasty is a common surgical procedure, but little is known about longitudinal trends in associated adverse outcomes. Our objective was to describe long-term trends in demographics, comorbidities, and adverse outcomes for older patients who underwent primary and revision total hip arthroplasty. METHODS We identified a retrospective, observational cohort of 1,405,379 Medicare beneficiaries who underwent primary total hip arthroplasty and 337,874 who underwent revision total hip arthroplasty between 1991 and 2008. The primary outcome was a composite representing the occurrence of one or more of the following adverse outcomes during the index admission or during readmission within ninety days after discharge: death, hemorrhage, infection, pulmonary embolism, sepsis, deep venous thrombosis, and myocardial infarction. Secondary outcomes included each of these outcomes assessed individually. RESULTS Between 1991 and 2008, the mean age and the mean comorbidity burden increased for all total hip arthroplasty patients. The length of hospital stay after primary and revision total hip arthroplasty declined by approximately 50% over the study period. However, the rate of readmission for any cause has recently increased and has surpassed 10% for primary total hip arthroplasty and 20% for revision total hip arthroplasty. The composite rate of adverse outcomes after primary total hip arthroplasty declined from 4% to 3.4% over the study period, whereas the composite adverse outcome rate after revision total hip arthroplasty slowly increased from 7% to 10.9%. We observed a steady decline in the rates of most individual adverse outcomes after primary total hip arthroplasty over the majority of the study period. Many of these rates stabilized or began to increase slightly near the end of the study period. In contrast, an increase in the rates of many adverse outcomes was observed in the revision total hip arthroplasty population even after accounting for changes in patient complexity. Postoperative hemorrhage has gradually increased after both primary and revision total hip arthroplasty. CONCLUSIONS Patients undergoing primary and revision total hip arthroplasty are becoming more complex. Despite this increasing complexity, patient outcomes for primary total hip arthroplasty improved markedly before stabilizing in recent years. In contrast, patient outcomes after revision total hip arthroplasty have gradually worsened, likely reflecting the increase in the medical comorbidities and surgical complexity of these patients. Length of hospital stay has demonstrated a substantial decline, which has recently been coupled with an increased readmission rate. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Automated External Defibrillators and Survival After In-Hospital Cardiac Arrest

CONTEXT Automated external defibrillators (AEDs) improve survival from out-of-hospital cardiac arrests, but data on their effectiveness in hospitalized patients are limited. OBJECTIVE To evaluate the association between AED use and survival for in-hospital cardiac arrest. DESIGN, SETTING, AND PATIENTS Cohort study of 11,695 hospitalized patients with cardiac arrests between January 1, 2000, and August 26, 2008, at 204 US hospitals following the introduction of AEDs on general hospital wards. MAIN OUTCOME MEASURE Survival to hospital discharge by AED use, using multivariable hierarchical regression analyses to adjust for patient factors and hospital site. RESULTS Of 11,695 patients, 9616 (82.2%) had nonshockable rhythms (asystole and pulseless electrical activity) and 2079 (17.8%) had shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia). AEDs were used in 4515 patients (38.6%). Overall, 2117 patients (18.1%) survived to hospital discharge. Within the entire study population, AED use was associated with a lower rate of survival after in-hospital cardiac arrest compared with no AED use (16.3% vs 19.3%; adjusted rate ratio [RR], 0.85; 95% confidence interval [CI], 0.78-0.92; P < .001). Among cardiac arrests due to nonshockable rhythms, AED use was associated with lower survival (10.4% vs 15.4%; adjusted RR, 0.74; 95% CI, 0.65-0.83; P < .001). In contrast, for cardiac arrests due to shockable rhythms, AED use was not associated with survival (38.4% vs 39.8%; adjusted RR, 1.00; 95% CI, 0.88-1.13; P = .99). These patterns were consistently observed in both monitored and nonmonitored hospital units where AEDs were used, after matching patients to the individual units in each hospital where the cardiac arrest occurred, and with a propensity score analysis. CONCLUSION Among hospitalized patients with cardiac arrest, use of AEDs was not associated with improved survival.

Cost‐effectiveness of Automated External Defibrillator Deployment in Selected Public Locations

OBJECTIVE: The American Heart Association (AHA) recommends an automated external defibrillator (AED) be considered for a specific location if there is at least a 20% annual probability the device will be used. We sought to evaluate the cost-effectiveness of the AHA recommendation and of AED deployment in selected public locations with known cardiac arrest rates.DESIGN: Markov Decision Model employing a societal perspective.SETTING: Selected public locations in the United States.PATIENTS: A simulated cohort of the American public.INTERVENTION: Strategy 1: individuals experiencing cardiac arrest were treated by emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals were treated with AEDs deployed as part of a public access defibrillation program. Strategies differed only in the initial availability of an AED and its impact on cardiac arrest survival.RESULTS: Under the base-case assumption that a deployed AED will be used on 1 cardiac arrest every 5 years (20% annual probability of AED use), the cost per quality-adjusted life year (QALY) gained is

The Costs of Critical Care Telemedicine Programs: A Systematic Review and Analysis

30,000 for AED deployment compared with EMS-D care. AED deployment costs less than

Medical tourism services available to residents of the United States.

50,000 per QALY gained provided that the annual probability of AED use is 12% or greater. Monte Carlo simulation conducted while holding the annual probability of AED use at 20% demonstrated that 87% of the trials had a cost-effectiveness ratio of less than

Failure to recognize and act on abnormal test results: the case of screening bone densitometry.

50,000 per QALY.CONCLUSIONS: AED deployment is likely to be cost-effective across a range of public locations. The current AHA guidelines are overly restrictive. Limited expansion of these programs can be justified on clinical and economic grounds.OBJECTIVE: The American Heart Association (AHA) recommends an automated external defibrillator (AED) be considered for a specific location if there is at least a 20% annual probability the device will be used. We sought to evaluate the cost-effectiveness of the AHA recommendation and of AED deployment in selected public locations with known cardiac arrest rates. DESIGN: Markov Decision Model employing a societal perspective. SETTING: Selected public locations in the United States. PATIENTS: A simulated cohort of the American public. INTERVENTION: Strategy 1: individuals experiencing cardiac arrest were treated by emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals were treated with AEDs deployed as part of a public access defibrillation program. Strategies differed only in the initial availability of an AED and its impact on cardiac arrest survival. RESULTS: Under the base-case assumption that a deployed AED will be used on 1 cardiac arrest every 5 years (20% annual probability of AED use), the cost per quality-adjusted life year (QALY) gained is