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Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Hip Arthroplasty: A Retrospective Cohort Study

Tang, Alex; Zak, Stephen; Iorio, Richard; Slover, James; Bosco, Joseph; Schwarzkopf, Ran
BACKGROUND:Currently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID. METHODS:In 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome. RESULTS:From 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53). CONCLUSION/CONCLUSIONS:Using a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.
PMID: 32334898
ISSN: 1532-8406
CID: 4411682

The Cost of an Episode of Care in a Total Knee Arthroplasty Patient Is More Than a Total Hip Arthroplasty Patient Within an Alternative Payment Model

Bernstein, Jenna A; Yeroushalmi, David; Slover, James D; Bosco, Joseph A
BACKGROUND:Alternative payment models were set up to increase the value of care for total joint arthroplasty. Currently, total knee arthroplasty (TKA) and total hip arthroplasty (THA) are reimbursed within the same bundle. We sought to determine whether it was appropriate for these cases to be included within the same bundle. METHODS:The data were collected from consecutive patients in a bundled payment program at a single large academic institution. All payments for 90 days postoperatively were included in the episode of care. Readmission rates, demographics, and length of stay were collected for each episode of care. RESULTS:There was a significant difference in cost of episode of care between TKA and THA, with the average TKA episode-of-care cost being higher than the average THA episode-of-care cost ($25803 vs $23805, P < .0001). There was a statistically significant difference between the 2 groups between gender, race, medical complexity, disposition outcome, and length of stay. The TKA group trended toward a lower readmission rate (5.3%) compared to the THA group (6.6%). CONCLUSION/CONCLUSIONS:The cost of an episode of care for patients within the bundled payment model is significantly higher for patients undergoing TKA compared with those undergoing a THA. This should be taken into consideration when determining payment plans for patients in alternative payment plans, along with other aspects of risk that need to be considered in order to allow for hospitals to be successful under the bundled payment model.
PMID: 32362481
ISSN: 1532-8406
CID: 4429792

Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective

Egol, Kenneth A; Konda, Sanjit R; Bird, Mackenzie L; Dedhia, Nicket; Landes, Emma K; Ranson, Rachel A; Solasz, Sara J; Aggarwal, Vinay K; Bosco, Joseph A; Furgiuele, David L; Ganta, Abhishek; Gould, Jason; Lyon, Thomas R; McLaurin, Toni M; Tejwani, Nirmal C; Zuckerman, Joseph D; Leucht, Philipp
OBJECTIVES/OBJECTIVE:To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN/METHODS:Prospective cohort study SETTING:: Seven musculoskeletal care centers with New York City and Long Island. PATIENTS/PARTICIPANTS/METHODS:138 recent and 115 historical hip fracture patients. INTERVENTION/METHODS:Patients with hip fractures occurring between February 1, 2020 and April 15, 2020 or between February 1, 2019 and April 15, 2019 were prospectively enrolled in an orthopedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs) or COVID negative (C-). MAIN OUTCOME MEASUREMENTS/METHODS:Hospital quality measures, inpatient complications and mortality rates. RESULTS:Seventeen (12.2%) patients were confirmed C+ by testing and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared to Cs and C- cohorts, had: an increased mortality rate (35.3% vs 7.1% vs 0.9%), increased length of hospital stay, a greater major complication rate and a greater incidence of ventilator need postoperatively. CONCLUSIONS:COVID-19 had a devastating effect on the care of hip fracture patients during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in hip fracture patients complicated by COVID-19. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
PMID: 32482976
ISSN: 1531-2291
CID: 4468782

Smoking cessation correlates with a decrease in infection rates following total joint arthroplasty

Herrero, Christina; Tang, Alex; Wasterlain, Amy; Sherman, Scott; Bosco, Joseph; Lajam, Claudette; Schwarzkopf, Ran; Slover, James
Background/UNASSIGNED:The impact of tobacco use on perioperative complications, hospital costs, and survivorship in total joint arthroplasty (TJA) is well established. The aim of this study is to report the impact of tobacco cessation on outcomes after TJA and to measure the impact of a voluntary smoking cessation program (SCP) on self-reported smoking quit rates in a premier academic medical center. Methods/UNASSIGNED:A seven-year (2013-2019) SCP database was provided by the Integrative Health Promotion Department and Infection Prevention and Control Department. We evaluated program and smoking status, patient demographics, length of stay (LOS), and 90-day post-operative infection rates and readmission rates. The primary outcome was quit rates based on SCP enrollment status. The secondary outcomes measured infection rates, readmission rates, and LOS based on enrollment status and/or quit rate. Results/UNASSIGNED:A total of 201 eligible patients were identified: 137 patients in the SCP (intervention) group and 64 in the self-treatment (control) group. SCP patients trended towards higher quit rates (43% vs 33%, p = 0.17), shorter LOS (2.47 vs 2.62 days, p = 0.52), lower infection rates (7.3% vs 12.5%, p = 0.27) and slightly higher readmission rates (5.8% vs 4.7%, p = 0.73). In a sub-analysis, self-reported smokers demonstrated statistically significant decrease in infection (3.7% vs 12.5%, p = 0.03). Conclusion/UNASSIGNED:There was a statistically significant decrease in infection rates in patients who self-reported quitting tobacco prior to TJA. Additionally, quit rates for patients who participated in a voluntary SCP trended towards increased pre-operative cessation. Further efforts to increase tobacco cessation prior to TJA and examine the impact on patient outcomes are needed.
PMCID:7475516
PMID: 32921947
ISSN: 0972-978x
CID: 4596262

Opioid Stewardship in Orthopaedic Surgery: Principles and Practice

Haskel, Jonathan D; Yousafzai, Mehek; Bloom, David A; Hutzler, Lorraine; Lemos, Connor; Bosco, Joseph A; Campbell, Kirk A
PMID: 32960027
ISSN: 2329-9185
CID: 4605592

Reemergence of Multispecialty Inpatient Elective Orthopaedic Surgery During the COVID-19 Pandemic: Guidelines for a New Normal

Anoushiravani, Afshin A; Barnes, C Lowry; Bosco, Joseph A; Bozic, Kevin J; Huddleston, James I; Kang, James D; Ready, John E; Tornetta, Paul; Iorio, Richard
PMID: 32675667
ISSN: 1535-1386
CID: 4528492

American Association of Hip and Knee Surgeons Advocacy Efforts in Response to the SARS-CoV-2 Pandemic

Huddleston, James I; Iorio, Richard; Bosco, Joseph A; Kerr, Joshua M; Bolognesi, Michael P; Barnes, C Lowry
As soon as it became clear that our economy was going to be paralyzed by the SARS-CoV-2 pandemic, the American Association of Hip and Knee Surgeons leadership acted swiftly to ensure that our members were going to be eligible for the anticipated federal economic stimulus. The cessation of elective surgery, enacted in mid-March and necessary to stop the spread of the SARS-CoV-2 virus, would surely challenge the solvency of many of our members' practices. Although our advocacy efforts discussed further have helped, clearly more relief is needed. Fortunately, our mitigation efforts have led to a "flattening of the curve" and discussions have begun on when, where, and how to safely start elective surgery again.
PMID: 32354537
ISSN: 1532-8406
CID: 4412802

The Response of an Orthopedic Department and Specialty Hospital at the Epicenter of a Pandemic: The NYU Langone Health Experience

Schwarzkopf, Ran; Maher, Nolan A; Slover, James D; Strauss, Eric J; Bosco, Joseph A; Zuckerman, Joseph D
As the world grapples with the COVID-19 pandemic, we as health care professionals thrive to continue to help our patients, and as orthopedic surgeons, this goal is ever more challenging. As part of a major academic tertiary medical center in New York City, the orthopedic department at New York University (NYU) Langone Health has evolved and adapted to meet the challenges of the COVID pandemic. In our report, we will detail the different aspects and actions taken by NYU Langone Health as well as NYU Langone Orthopedic Hospital and the orthopedic department in particular. Among the steps taken, the department has reconfigured its staff's assignments to help both with the institution's efforts and our patients' needs from reassigning operating room nurses to medical COVID floors to having attending surgeons cover urgent care locations. We have reorganized our residency and fellowship rotations and assignments as well as adapting our educational programs to online learning. While constantly evolving to meet the institution's and our patient demands, our leadership starts planning for the return to a new "normal".
PMCID:7195373
PMID: 32376169
ISSN: 1532-8406
CID: 4427822

Every Challenge is an Opportunity

Bosco, Joseph A
PMID: 32496406
ISSN: 1940-5480
CID: 4469232

The Corporate Practice of Medicine: Ethical Implications of Orthopaedic Surgery Practice Ownership by Non-Physicians

Moses, Michael J; Weiser, Lori G; Bosco, Joseph A
There has been an upsurge in the number of practices owned by non-physicians. With orthopaedic surgery as the next frontier in this market, orthopaedists need to consider the ethical consequences of such acquisitions. The history and trends of practice ownership are reviewed alongside how laws shifted to reflect a changing health-care climate. The 4 tenets of bioethics (beneficence, nonmaleficence, autonomy, and justice) are explored with regard to practice acquisition by non-physician entities. Although non-physician-owned corporations and private equity firms provide liquidity to the health-care sector, there are ethical concerns that may ultimately impact patient care. Orthopaedic surgeons must be cautious when engaging in acquisitions with non-physician-owned entities, as the goals of each party may not align. This may yield situations that infringe on the basic principles of bioethics for both physician and patient.
PMID: 32496745
ISSN: 1535-1386
CID: 4469282