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The Forgotten Joint Score patient-acceptable symptom state following primary total hip arthroplasty

Singh, Vivek; Bieganowski, Thomas; Huang, Shengnan; Karia, Raj; Davidovitch, Roy I; Schwarzkopf, Ran
AIMS/OBJECTIVE:The Forgotten Joint Score-12 (FJS-12) is a validated patient-reported outcome measure (PROM) tool designed to assess artificial prosthesis awareness during daily activities following total hip arthroplasty (THA). The patient-acceptable symptom state (PASS) is the minimum cut-off value that corresponds to a patient's satisfactory state-of-health. Despite the validity and reliability of the FJS-12 having been previously demonstrated, the PASS has yet to be clearly defined. This study aims to define the PASS of the FJS-12 following primary THA. METHODS:We retrospectively reviewed all patients who underwent primary elective THA from 2019 to 2020, and answered both the FJS-12 and the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR) questionnaires one-year postoperatively. HOOS, JR score was used as the anchor to estimate the PASS of FJS-12. Two statistical methods were employed: the receiver operating characteristic (ROC) curve point, which maximized the Youden index; and 75th percentile of the cumulative percentage curve of patients who had the HOOS, JR score difference larger than the cut-off value. RESULTS:This study included 780 patients. The mean one-year FJS-12 score was 65.42 (SD 28.59). The mean one-year HOOS, JR score was 82.70 (SD 16.57). A high positive correlation between FJS-12 and HOOS, JR was found (r = 0.74; p<0.001), making the HOOS, JR a valid external anchor. The threshold score of the FJS-12 that maximized the sensitivity and specificity for detecting a PASS was 66.68 (area under the curve = 0.8). The cut-off score value computed with the 75th percentile approach was 92.20. CONCLUSION/CONCLUSIONS: 2022;3(4):307-313.
PMID: 35387474
ISSN: 2633-1462
CID: 5219652

Patient Acceptable Symptom State for the Forgotten Joint Score in Primary Total Knee Arthroplasty

Singh, Vivek; Fiedler, Benjamin; Huang, Shengnan; Oh, Cheongeun; Karia, Raj J; Schwarzkopf, Ran
BACKGROUND:In order to better understand the clinical benefits of total knee arthroplasty (TKA) and improve the interpretability of the Forgotten Joint Score (FJS-12), the establishment of a meaningful change in score is necessary. The purpose of this study is to determine the threshold of the FJS-12 for detecting the patient acceptable symptom state (PASS) following primary TKA. METHODS:percentile of the cumulative percentage curve of patients who had the KOOS, JR score difference larger than the cut-off value. RESULTS:percentile approach was 77.1 (95% CI [73.9, 81.5]). CONCLUSION/CONCLUSIONS:percentile approaches, respectively. These values can be used to assess the successful achievement of a forgotten joint. LEVEL III EVIDENCE/METHODS:Retrospective Cohort Study.
PMID: 35346809
ISSN: 1532-8406
CID: 5200952

Age and Gender Confound PROMIS Scores in Spine Patients With Back and Neck Pain

Jevotovsky, David S; Tishelman, Jared C; Stekas, Nicholas; Moses, Michael J; Karia, Raj J; Ayres, Ethan W; Fischer, Charla R; Buckland, Aaron J; Errico, Thomas J; Protopsaltis, Themistocles S
STUDY DESIGN/UNASSIGNED:This was a single-center retrospective review. OBJECTIVES/UNASSIGNED:To explore how age and gender affect PROMIS scores compared with traditional health-related quality of life (HRQL) in spine patients. METHODS/UNASSIGNED:Patients presenting with a primary complaint of back pain (BP) or neck pain (NP) were included. Legacy HRQLs were Oswestry Disability Index (ODI), Neck Disability Index (NDI), and Visual Analogue Scale (VAS). PROMIS Physical Function (PF), Pain Intensity (Int), and Pain Interference (Inf) were also administered to patients in a clinical setting. Patients were grouped by chief complaint, age (18-44, 45-64, 65+ years) and gender. Two parallel analyses were conducted to identify the effects of age and gender on patient-reported outcomes. Age groups were compared after propensity-score matching by VAS-pain and gender. Separately, genders were compared after propensity-score matching by age and VAS-pain. RESULTS/UNASSIGNED:= .022) but not PROMIS-Int or PROMIS-Inf. CONCLUSIONS/UNASSIGNED:Age and gender confound traditional HRQLs as well as PROMIS domains. However, PROMIS offers age and gender-specific scores, which traditional HRQLs lack.
PMID: 32875861
ISSN: 2192-5682
CID: 4583312

Pediatric Fingertip Injuries: Association With Child Abuse

Klifto, Christopher S; Lavery, Jessica A; Gold, Heather T; Milone, Michael T; Karia, Raj; Palusci, Vincent; Chu, Alice
Purpose/UNASSIGNED:Pediatric fingertip injuries are most commonly reported in the setting of an accidental occurrence. The purpose of this study was to determine whether there is an association of child abuse and neglect with pediatric fingertip injuries. Methods/UNASSIGNED:The New York Statewide Planning and Research Cooperative System (2004 to 2013) administrative database was used to identify children aged 0 to 12 years who presented in the inpatient or outpatient (emergency department or ambulatory surgery) setting. International Classification of Diseases, Ninth Revision diagnosis codes were used to identify fingertip injuries (amputation, avulsion, or crushed finger) and abuse. Cohort demographics of children presenting with fingertip injuries were described. We analyzed the association between fingertip injuries and child abuse using multivariable logistic regression, with variables for insurance status, race, ethnicity, sex, and behavioral risks including depression, attention-deficit hyperactivity disorder, aggressive behavior, and autism. Results/UNASSIGNED:Of the 4,870,299 children aged 0 to 12 years in the cohort, 79,108 patients (1.62%) during the study period (2004 to 2013) presented with fingertip injuries. Of those with a fingertip injury, 0.27% (n = 216) presented either at that visit or in other visits with a code for child abuse, compared with 0.22% of pediatric patients without a fingertip injury (n = 10,483). In an adjusted analysis, the odds of a fingertip injury were 23% higher (odds ratio [OR] = 1.23; 95% confidence interval [CI], 1.07-1.41) for children who had been abused, compared with those who had not. Patients were more likely to present with fingertip injuries if they had ever had Medicaid insurance (OR = 1.40; 95% CI, 1.37-1.42) or had a behavioral risk factor (OR = 1.35; 95% CI, 1.30-1.40). Conclusions/UNASSIGNED:Patients presenting with abuse are significantly more likely to have fingertip injuries during childhood compared with those without recorded abuse, which suggests that these injuries may be ones of abuse or neglect. Medicaid insurance, white race, and behavioral diagnoses of depression, attention-deficit hyperactivity disorder, aggressive behavior, and autism were also associated with increased odds of presenting with fingertip injuries. Type of study/level of evidence/UNASSIGNED:Prognostic III.
PMID: 35415471
ISSN: 2589-5141
CID: 5232462

A Review of Orthopedic Resident Outpatient Notes Are Perceptions of the EMR Reflected in Current Documentation Practices?

Phillips, Donna; Fisher, Nina; Karia, Raj; Kalet, Adina
INTRODUCTION/BACKGROUND:Systems-based Practice 3 (SBP 3) in the orthopedic residency developmental milestones evaluates residents' knowledge, understanding, and utilization of the electronic medical record (EMR). In order to better assess SBP 3, we conducted a review of residents' clinical notes in order to quantify the current state of orthopedic residents' documentation in the EMR. The purpose of this study was to objectively evaluate orthopedic resident documentation in the EMR. METHODS:Orthopedic resident medical notes from a single orthopedic residency at one academic medical center were scored by faculty members who had directly observed the clinical encounter. These notes were then independently scored by one investigator (N.F.) using clinical contentspecific, objective criteria. Sixty-five medical records were reviewed. All 62 orthopedic residents anonymously completed an 84-question survey on the value of EMR utilization and documentation within the medical record. RESULTS:Many key elements necessary to diagnosing a patient's injury and developing a treatment plan were often omitted (e.g., "Mechanism of Injury" in 32.3% of records), and the majority of notes did not include "Decision Making and Patient Preference" (95.2%) or "Risks/Benefits of Surgery" (93.7%). However, 95.2% of residents agreed that their notes reflect their medical knowledge and 96.8% agreed that their notes reflect their clinical reasoning. DISCUSSION/CONCLUSIONS:The results of this objective review revealed significant deficits in orthopedic resident documentation not identified by faculty observers.
PMID: 31487485
ISSN: 2328-5273
CID: 4153432

The Effect of Length of Stay and Discharge Disposition on Hospital Consumer Assessment of Healthcare Providers and Systems Scores in Orthopaedic Patients

Shulman, Brandon; Hutzler, Lorraine; Karia, Raj; Bosco, Joseph
BACKGROUND:The study assesses whether Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores were influenced by hospital length of stay (LOS) and discharge disposition. METHODS:HCAHPS scores from 5,682 orthopaedic patients were collected over a 4-year period. Statistical analyses were run to identify associations between Top-Box scores for each HCAHPS domain and LOS or discharge disposition (home versus rehabilitation facility). RESULTS:Decreased LOS was associated with increased HCAHPS Top-Box scores for every Top-Box domain except for Discharge composite (P ≤ 0.001 to 0.011). Discharge to home was associated with increased HCAHPS scores for four Top-Box domains (P ≤ 0.001 to 0.009). DISCUSSION/CONCLUSIONS:Shorter LOS and discharge to home after orthopaedic surgery are associated with better HCAHPS scores. Earlier discharge leads to an improved patient-reported experience and can increase reimbursements. Expedient, appropriate discharge of hospitalized orthopaedic patients should be a treatment goal after orthopaedic surgery.
PMID: 30379757
ISSN: 1940-5480
CID: 3401082

Corrigendum to 'Relationship Between the Patient-Reported Outcome Measurement Information System and Traditional Patient-Reported Outcomes for Osteoarthritis' [The Journal of Arthroplasty 34 (2019) 265-272]

Padilla, Jorge A; Rudy, Hayeem L; Gabor, Jonathan A; Friedlander, Scott; Iorio, Richard; Karia, Raj J; Slover, James D
PMID: 30852067
ISSN: 1532-8406
CID: 3732842

Lack of Cost Savings for Lumbar Spine Fusions After Bundled Payments for Care Improvement Initiative: A Consequence of Increased Case Complexity

Bronson, Wesley H; Kingery, Matthew T; Hutzler, Lorraine; Karia, Raj; Errico, Thomas; Bosco, Joseph; Bendo, John A
STUDY DESIGN/METHODS:Retrospective analysis of Medicare claims and procedure details from a single institution participation in the Bundled Payments for Care Improvement (BPCI) program. OBJECTIVE:To analyze the effects of the BPCI program on patient outcome metrics and cost data. SUMMARY OF BACKGROUND DATA/BACKGROUND:The BPCI program was designed to improve the value of care provided to patients, but the financial consequences of this system remain largely unknown. We present two years of data from participation in the lumbar spine fusion bundle at a large, urban, academic institution. METHODS:In 2013 and 2014, all Medicare patients undergoing lumbar spine fusions for DGR 459 (spinal fusion except cervical with MCC) and 460 (without MCC) at our institution were enrolled in the BPCI program. We compared the BPCI cohort to a baseline cohort of patients under the same DRGs from 2009 to 2012 from which the target price was established. RESULTS:350 patients were enrolled into the BPCI program, while the baseline group contained 518 patients. When compared to the baseline cohort, length of stay decreased (4.58 +/- 2.51 vs 5.13 +/- 3.75; p = 0.009), readmission rate was unchanged, and discharges with HHA increased. Nonetheless, we were unable to effect an episode-based cost savings ($52,655 +/- 27,028 vs $48,913 +/- 24,764). In the larger DRG 460 group, total payments increased in the BPCI group ($51,105 +/- 26,347 vs $45,934 +/- 19,638, p = 0.001). Operative data demonstrated a more complex patient mix in the BPCI cohort. The use of interbody fusions increased from 2% to 16% (p < 0.001), and the percentage of complex spines increased from 23% to 45% (p < 0.001). CONCLUSIONS:Increased case complexity was responsible for increasing costs relative to the negotiated baseline target price. This payment system may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and technologies. LEVEL OF EVIDENCE/METHODS:3.
PMID: 30045344
ISSN: 1528-1159
CID: 3216472

Comparison of Patient Reported Outcome Measurement Information System (PROMIS) with Neck Disability Index (NDI) and Visual Analog Scale (VAS) in Patients with Neck Pain

Moses, Michael J; Tishelman, Jared C; Stekas, Nicholas; Jevotovsky, David S; Vasquez-Montes, Dennis; Karia, Raj; Errico, Thomas; Buckland, Aaron; Protopsaltis, Themistocles S
STUDY DESIGN/METHODS:A retrospective analysis of a patient-reported outcomes database from a single institution from December 2016 to April 2017. OBJECTIVE:To validate the association of PROMIS with NDI in patients with neck pain and examine each instruments ability to capture concomitant arm pain and concomitant back pain. SUMMARY OF BACKGROUND DATA/BACKGROUND:PROMIS has been increasingly utilized and its computer adapted testing methodology improves assessment of pain and disability. However literature is lacking regarding how these instruments perform in neck pain patients with concomitant arm pain or back pain. METHODS:Inclusion criteria were age>18years and a primary complaint of neck pain. The NDI, VAS Back, Neck, Arm and Leg, and PROMIS Physical Function, Pain Intensity, and Pain Interference questionnaires were administered. Propensity score matching was performed to compare patients with high and low back and arm pain while controlling for neck pain. Bivariate correlations and independent samples t-tests were performed to assess linear relationships and compare back and arm pain groups with PROMIS. RESULTS:130 patients were included. NDI correlated strongly to PROMIS Physical Function (r = -0.771, p < 0.001), Pain Intensity (r = 0.605, p < 0.001), and Pain Interference (r = 0.786, p < 0.001). VAS Neck and Arm Pain also correlated to the PROMIS Pain Intensity instrument (VAS Neck: r = 0.642, p < 0.001; VAS Arm: r = 0.376, p < 0.001).Following matching for neck pain, the high and low back pain groups each included 32 patients. There were significant differences in PROMIS Physical Function when high and low back pain groups were compared (39.07 vs 43.68, p = 0.031). No significant difference was found for any outcome metric for high and low arm pain groups. CONCLUSIONS:PROMIS instruments are capable of characterizing pain and disability in patients with neck pain and are sensitive to disability in regions adjacent to the neck. LEVEL OF EVIDENCE/METHODS:3.
PMID: 30015716
ISSN: 1528-1159
CID: 3200652

Patient-Reported Outcomes Measurement Information System instruments: outperforming traditional quality of life measures in patients with back and neck pain

Tishelman, Jared C; Vasquez-Montes, Dennis; Jevotovsky, David S; Stekas, Nicholas; Moses, Michael J; Karia, Raj J; Errico, Thomas; Buckland, Aaron J; Protopsaltis, Themistocles S
OBJECTIVEThe Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular due to computer adaptive testing methodology. This study aims to validate the association between PROMIS and legacy outcome metrics and compare PROMIS to legacy metrics in terms of ceiling and floor effects and questionnaire burden.METHODSA retrospective review of an outcomes database was performed at a single institution from December 2016 to April 2017. Inclusion criteria were age > 18 years and a chief complaint of back pain or neck pain. The PROMIS computer adaptive testing Pain Interference, Physical Function (PF), and Pain Intensity domains; Oswestry Disability Index (ODI); Neck Disability Index (NDI); and visual analog scale (VAS) back, VAS leg, VAS neck, and VAS arm were completed in random order. PROMIS was compared to legacy metrics in terms of the average number of questions needed to complete each questionnaire and the score distributions in the lower and higher bounds of scores.RESULTSA total of 494 patients with back pain and 130 patients with neck pain were included. For back pain, ODI showed a strong correlation with PROMIS-PF (R = -0.749, p < 0.001), Pain Intensity (R = 0.709, p < 0.001), and Pain Interference (R = 0.790, p < 0.001) domains. Additionally, the PROMIS Pain Intensity domain correlated to both VAS back and neck pain (R = 0.642, p < 0.001 for both). PROMIS-PF took significantly fewer questions to complete compared to the ODI (4.123 vs 9.906, p < 0.001). When assessing for instrument sensitivity, neither survey presented a significant ceiling and floor effect in the back pain population (ODI: 0.40% and 2.63%; PROMIS-PF: 0.60% and 1.41%). In the neck pain cohort, NDI showed a strong correlation with PROMIS-PF (R = 0.771, p < 0.001). Additionally, PROMIS Pain Intensity correlated to VAS neck (R = 0.642, p < 0.001). The mean number of questions required to complete the questionnaire was much lower for PROMIS-PF compared to NDI (4.417 vs 10, p < 0.001). There were no significant differences found in terms of ceiling and floor effects for neck complaints (NDI: 2.3% and 6.92%; PROMIS-PF: 0.00% and 5.38%) or back complaints (ODI: 0.40% and 2.63%; PROMIS-PF: 1.41% and 0.60%).CONCLUSIONSPROMIS correlates strongly with traditional disability measures in patients with back pain and neck pain. For both back and neck pain, the PROMIS-PF required patients to answer significantly fewer questions to achieve similar granularity. There were no significant differences in ceiling and floor effects for NDI or ODI when compared with the PROMIS-PF instrument.
PMID: 30717038
ISSN: 1547-5646
CID: 3683982