Faculty Bibliography

Introduction/objectives: In this study, we evaluate the application of preoperative PRO scores, such as the Hip dysfunction and Osteoarthritis Outcomes Score (HOOS) and EuroQol-5Dimension (EQ-5D), as potential predictive modelling tools to anticipate adverse in-hospital outcomes. Methods: Patients between the ages of 18 to 95 undergoing a primary THA between January 2015 and January 2017 at this institution were chart reviewed for inclusion in this study. 40% of our patient population completed preoperative PRO scores within 1 year of surgery and were included in this study. Nursing documentation was reviewed for patient demographics and in-hospital course metrics, such as visual analogue scale (VAS) for pain and morphine equivalence usages. EQ-5D was noted to be binomially distributed and subsequently transformed into a categorical variable with patients scoring >50% placed into a "high EQ-5D" group, and those scoring below into a "low EQ-5D" group. Results: In total, 349 patients including 157 males and 192 females were recruited for this study. The average age and body mass index (BMI) was 62.4+/-11.0 years and 28.6+/-5.61 kg/m2, respectively. The median American Society of Anesthesiology (ASA) Score within our patient cohort was 2. Of the pre-operative scores, age, BMI, EQ-5D, and HOOS section scores were compared with average daily pain, all but age were significantly correlated. However, these values had low r2 values <0.1, indicating poor predictive strength. Conclusion: Our study demonstrates that baseline PRO scores, such as the HOOS and EQ-5D, contain a small predictive component for in-hospital pain scores and average daily morphine. Furthermore, PRO tools can potentially be used to develop systematic, predictive risk stratification models

Introduction/objectives: As surgeons, we have a moral obligation to address potentially preventable complications in an effort to improve total hip arthroplasty (THA) outcomes. The goal of this study is to identify and report potentially preventable causes for revision THA (rTHA). Methods: A retrospective review of 352 consecutive patients that underwent rTHA or re-revision THA from August 2015 to August 2017 was conducted. 138 of these were identified as primary to rTHA within a 5 year interval. Two adult reconstruction fellowship trained surgeons reviewed perioperative parameters and classified rTHA recipients into two categories: preventable rTHA and nonpreventable rTHA. Basic demographics, surgical characteristics for the primary THA (pTHA), and pre- and post-rTHA variables were analyzed. Results: Sixty (43.5%) rTHAs were deemed preventable. Of these rTHA recipients, 20 were male and 40 were female. Mean age at time of rTHA was 61.5 years and mean body mass index was 27.8 kg/m2. The following were identified as preventable reasons for rTHA: cup malpositioning (70%), instability (53%), intra-operative fracture (40%), history of spinal surgery/deformity (22%), aseptic loosening (20%), femoral component subsidence (15%), and other (18%). The most common bearing surface during pTHA was cobalt chrome on highly crosslinked polyethylene (40%). The most common femoral head size was 36mm (38%). Technology was used for assistance in 8.3% of pTHAs. Four patients (6.7%) underwent re-revision THA, three for instability and one for aseptic loosening. Conclusion: A high proportion (43.4%) of rTHA is potentially preventable. Furthermore, surgeons are responsible for carefully evaluating causes for rTHA and identifying new methods to address these issues

BACKGROUND:The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally reported survey of patients' perspectives of hospital care that is used for hospital comparison and reimbursement. Although the survey attempts to correct for many factors that may affect scoring, socioeconomic factors are not considered in score weighting. The purpose of this study was to analyze the effect of socioeconomic status on HCAHPS scores. PATIENTS AND METHODS/METHODS:HCAHPS scores from 15,789 patients were collected. All patients were seen at a single academic medical center from 2010 to 2014, thus controlling for quality of care. HCAHPS Top Box scores were then compared to patient socioeconomic status based on the median income of the ZIP Code for each patient. RESULTS:Median income was negatively associated with patients' overall hospital rating (p < 0.001) and willingness to recommend hospital (p < 0.001). When controlling for the current adjustment factors (age, education, primary language, health status, and emergency admission), living in a ZIP Code with a median household income above $100,000 per year was independently associated with worse Top Box Scores for the categories of "Overall Hospital Rating" (p = 0.042), "Recommend Hospital" (p = 0.007), "Pain Management" (0.048), "Communication about Medicine" (p = 0.007), "Cleanliness of Hospital Environment" (p = 0.002), and "Quietness of Hospital Environment" (p < 0.001). CONCLUSION/CONCLUSIONS:Socioeconomic status independently affects HCAHPS scores. Patients living in ZIP Codes with lower median incomes generally rated hospitals better than patients with higher incomes. Therefore, treatment of a disproportionate number of low income patients cannot be cited as a pretext for poor HCAHPS scores.

BACKGROUND:As the number of total hip and knee arthroplasty cases increases, it is important to understand the burden of factors that impact patient outcomes of these procedures. This article examined the time trends in key demographics, clinical characteristics, comorbidity burden (Deyo-Charlson Comorbidity Index [CCI]), and presence of depression in patients undergoing primary total hip arthroplasty and total knee arthroplasty using population-based, all-payer inpatient database, California Healthcare Cost and Utilization Project, from 2007 to 2010. METHODS:Chi-square tests and analysis of variance were used. Multivariate logistic regression analyses were also performed to compare the prevalence of depression in 2007 to later years. RESULTS:In the primary total hip arthroplasty cohort, the prevalence of depression significantly increased by 20%, mean age decreased by 0.4 years, mean length of stay (LOS) decreased by 0.5 days, and having a CCI score of ≥3 increased by 30% (P value < .001 for all) over the study period. Similarly, in the primary total knee arthroplasty cohort, the prevalence of depression increased by 23%, the mean age decreased by 0.4 years, mean LOS decreased by 0.4 days, and the prevalence of CCI score of ≥3 increased by 35% (P value < .001 for all). CONCLUSION/CONCLUSIONS:Despite the younger age of the joint arthroplasty population over time, we found increased prevalence of depression and comorbidity scores but shorter LOS. Further study is needed to determine the impact of the changing demographics of the total joint population and the best strategies to optimize their outcome with these procedures.

BACKGROUND:Robotic and computer navigation technology is available to surgeons for use in hip and knee arthroplasties to increase the precision of component placement. However, they do add significant costs to these procedures, and the long-term clinical outcomes and value of technology assistance for joint replacement remain unclear. METHODS:We identified 321,522 patients in Medicare Severity Diagnosis Related Groups 469 and 470 who underwent primary total hip arthroplasty (N = 133,472) or primary total or unicompartmental knee arthroplasty (N = 188,050) between 2008 and 2015 in the New York Statewide Planning and Research Cooperative System (SPARCS). RESULTS:Among all total joint arthroplasties performed during this period, technology assistance was used in 5.1% of cases. Technology assistance was more common for knee (7.3%) than hip (1.9%) arthroplasty (P < .001). The proportion of cases using technology assistance grew each year, increasing from 2.8% (knee 4.3% and hip 0.5%) in 2008 to 8.6% (knee 11.6% and hip 5.2%) in 2015 (P trend <.001). The proportion of hospitals and surgeons using robotic assistance also increased during the study period, increasing from 16.2% of hospitals and 6.2% of surgeons in 2008 to 29.2% of hospitals and 17.1% of surgeons in 2015 (P trend <.001 for both). Technology was more likely to be used for patients with private insurance (5.9%) compared with Medicare (4.7%, P < .001) or Medicaid (2.2%, P < .001), and for patients at high-volume (6.9%, P < .001) or very high-volume (6.1%, P < .001) as compared with low-volume (2.7%) hospitals. CONCLUSION/CONCLUSIONS:Technology assistance has become increasingly used by orthopedic surgeons for hip and knee arthroplasties, however, adoption has not been uniform.

The purpose of this study was to compare nonelective and all-cause readmission rates and to identify risk factors for readmission of total joint arthroplasty (TJA) patients who had preoperative bariatric surgery (BS) compared with TJA patients without preoperative BS. The New York Statewide Planning and Research Cooperative System database was queried to identify 343,710 TJA patients between 2005 and 2014. Three patient groups were evaluated: group 1 (patients with preoperative BS within 2 years of TJA [N=1478]); group 2 (obese patients without preoperative BS [N=60,259]); and group 3 (nonobese patients without preoperative BS [N=281,973]). Nonelective and all-cause readmission rates (30 days, 90 days, and 1 year) were compared, and multivariate analyses of readmission risk factors were performed. Group 1 had no significant difference in nonelective readmission rates compared with groups 2 and 3. However, when elective TJA readmissions were included, group 1 had significantly higher all-cause readmission rates at 30 days, 90 days, and 1 year compared with groups 2 and 3. Bariatric surgery was not a risk factor for nonelective readmissions at any time point. When elective TJA admissions were included, BS was an independent risk factor for all-cause readmission at all time points. Patients who have BS prior to TJA do not have higher nonelective readmission rates than obese TJA patients without BS. Bariatric surgery is not a risk factor for nonelective readmissions. However, BS is a significant predictor of elective TJA admissions up to 1 year following the index TJA. [Orthopedics. 201x; xx(x):xx-xx.].

BACKGROUND:The Bundled Payments for Care Improvement initiative was developed to reduce costs associated with total joint arthroplasty through a single payment for all patient care from index admission through a 90-day post-discharge period, including care at skilled nursing facilities (SNFs). The aim of this study is to investigate whether forming partnerships between hospitals and SNFs could lower the post-discharge costs. We hypothesize that institutionally aligned SNFs have lower post-discharge costs than non-aligned SNFs. METHODS:A cohort of 615 elective, primary total hip and knee arthroplasty subjects discharged to an SNF under the Bundled Payments for Care Improvement from 2014 to 2016 were included in our analysis. Patients were grouped into one of the 3 categories of SNF alignment: group 1: non-partners; group 2: agreement-based partners; group 3: institution-owned partners. Demographics, comorbidities, length of stay (LOS) at SNF, and associated costs during the 90-day post-operative period were compared between the 3 groups. RESULTS:Mean index hospital LOS was statistically shortest in group 3 (mean 2.7 days vs 3.5 for groups 1 and 2, P = .001). SNF LOS was also shortest in group 3 (mean 11 days vs 19 and 21 days in groups 2 and 1 respectively, P < .001). Total SNF costs and total 90-day costs were both significantly lower in group 3 compared with groups 1 and 2 (P < .001 for all), even after controlling for medical comorbidities. CONCLUSION/CONCLUSIONS:Institution-owned partner SNFs demonstrated the shortest patient LOS, and the lowest SNF and total 90-day costs, without increased risk of readmissions, compared with other SNFs.

BACKGROUND:Individuals coinfected with both hepatitis C virus (HCV) and HIV represent a unique and growing population of patients undergoing orthopaedic surgical procedures. Data regarding complications for HCV monoinfection or HIV monoinfection are robust, but there are no data available, to our knowledge, on patients who have both HCV and HIV infections. QUESTIONS/PURPOSES/OBJECTIVE:We sought to determine whether patients with coinfection differed in terms of baseline demographics and comorbidity burden as compared with patients without coinfection and whether these potential differences were translated into varying levels of postoperative complications, mortality, and hospital readmission risk. Specifically, we asked: (1) Are there demonstrable differences in baseline demographic variables between patients infected with HCV and HIV and those who do not have those infections (age, sex, race, and insurance status)? (2) Do patients with HCV and HIV infection differ from patients without those infections in terms of other medical comorbidities? (3) Do patients with HCV/HIV coinfection have a higher incidence of early postoperative complications and mortality than patients without coinfection? (4) Is the frequency of readmission greater for patients with HCV/HIV coinfection than those without? METHODS:The New York Statewide Planning and Research Cooperative System (SPARCS) database was used to identify patients undergoing THA between 2010 and 2014. The SPARCS database is particularly useful because it captures 100% of all New York State inpatient admissions while providing detailed demographic and comorbidity data for a large, heterogeneous patient population with long-term followup. Patients were stratified into four groups based on HCV/HIV status: control patients without disease, HCV monoinfection, HIV monoinfection, and coinfection. We sought to determine whether patients coinfected with HCV and HIV would differ in terms of demographics from patients without those infections and whether patients with HCV and HIV would have a greater risk of complications, longer length of stay, and hospital readmission. A total of 80,722 patients underwent THA between 2010 and 2014. A total of 98.55% (79,554 of 80,722) of patients did not have either HCV or HIV, 0.66% (530 of 80,722) had HCV monoinfection, 0.66% (534 of 80,722) HIV monoinfection, and 0.13% (104 of 80,722) were coinfected with both HCV and HIV. Multivariate analysis was performed controlling for age, sex, insurance, residency status, diagnosis, and comorbidities to allow for an equal comparison between groups. RESULTS:Patients with coinfection were more likely to be younger, male (odds ratio [OR], 2.90; 95% confidence interval [CI], 2.20-3.13; p < 0.001), insured by Medicaid (OR, 6.43; 4.41-7.55; p < 0.001), have a history of avascular necrosis (OR, 8.76; 7.20-9.53; p < 0.001), and to be homeless (OR, 6.95; 5.31-7.28; p < 0.001) as compared with patients without HIV or HCV. Additionally, patients with coinfection had the highest proportion of alcohol abuse, drug abuse, and tobacco use along with a high proportion of psychiatric disorders, including depression. HCV and HIV coinfection were independent risk factors for increased length of stay (OR, 1.97; 95% CI, 1.29-3.01; p < 0.001), having two or more in-hospital complications (OR, 1.64; 1.01-2.67; p < 0.001), and 90-day readmission rates (OR, 2.97; 1.86-4.77; p < 0.001). CONCLUSIONS:As the prevalence of HCV and HIV coinfectivity continues to increase, orthopaedic surgeons will encounter a greater number of these patients. Awareness of the demographic and socioeconomic factors leading to increased complications after THA will allow physicians to consider interventions such as in-hospital psychiatric counseling, advanced discharge planning, and coordination with social work and collaboration with HCV/HIV infectious disease specialists to improve patient health status to improve outcomes and reduce costs. LEVEL OF EVIDENCE/METHODS:Level III, therapeutic study.

Background/UNASSIGNED:It is often assumed that each surgeon's patient population is similar to that of his or her peers. Differences in patient characteristics naturally may lead to diverse outcomes. To date, the variability of individual surgeons' patient populations has not been adequately characterized. The purpose of this study is to describe the variation in physician-specific patient characteristics among surgeons performing spine fusion surgery at a large, urban academic medical center. Methods/UNASSIGNED:We analyzed administrative data from a single institution for spine fusion surgery from 2009 to 2013. There were 6585 primary and 362 revision cases of spine fusion performed within this time period. Variability between surgeons and their respective patient populations was compared using descriptive statistics. Results/UNASSIGNED:The mean annual percentage of primary fusion patients with diabetes mellitus ranged from 0 to 16.17% (mean ± SD, 7.79% ± 3.96%) but constituted anywhere from 0 to 41.58% (mean ± SD, 8.15% ± 12.09%) of revision fusions. The mean annual percentage of primary fusion patients who were obese ranged from 0 to 9% (mean ± SD, 2.95% ± 2.7%), and 0 to 25% in revision cases (mean ± SD, 3.43% ± 6.43%). The annual mean percentage of patients with American Society of Anesthesiologists (ASA) scores greater than 3 ranged from 8.8% to 44.43% (mean ± SD, 20.42% ± 8.85%) in primary fusions and 0 to 100% (mean ± SD, 32.79% ± 23.47%) in revision fusions. Conclusion/UNASSIGNED:There was a large amount of variability among surgeons' patient populations when looking at characteristics such as obesity, diabetes, and ASA scores >3. These factors have been shown to impact patient outcomes. The variability in the patient populations of individual surgeons' practices even within the same medical center must be taken into account when evaluating physician specific outcomes and quality of care.

BACKGROUND: The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible. METHODS: We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities. RESULTS: Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m2 (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%). CONCLUSION: A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.