Offering patients the opportunity to choose their hospital for total knee replacement: Impact on satisfaction with the surgery

Medicaid Patients Undergo Total Joint Arthroplasty at Lower-Volume Hospitals by Lower-Volume Surgeons and Have Poorer Outcomes

BACKGROUND

Medicaid insurance coverage among patients undergoing total hip arthroplasty (THA) or those undergoing total knee arthroplasty (TKA) has been associated with worse postoperative outcomes compared with patients without Medicaid. Surgeons and hospitals with lower annual total joint arthroplasty (TJA) volume have also been associated with worse outcomes. This study sought to characterize the associations between Medicaid insurance status, surgeon case volume, and hospital case volume and to assess the rates of postoperative complications compared with other payer types.

METHODS

The Premier Healthcare Database was queried for all adult patients who underwent primary TJA from 2016 to 2019. Patients were divided on the basis of their insurance status: Medicaid compared with non-Medicaid. The distribution of annual hospital and surgeon case volume was assessed for each cohort. Multivariable analyses were performed accounting for patient demographic characteristics, comorbidities, surgeon volume, and hospital volume to assess the 90-day risk of postoperative complications by insurance status.

RESULTS

Overall, 986,230 patients who underwent TJA were identified. Of these, 44,370 (4.5%) had Medicaid. Of the patients undergoing TJA, 46.4% of those with Medicaid were treated by surgeons performing ≤100 TJA cases annually compared with 34.3% of those without Medicaid. Furthermore, a higher percentage of patients with Medicaid underwent TJA at lower-volume hospitals performing ≤500 cases annually, 50.8% compared with 35.5% for patients without Medicaid. After accounting for differences among the 2 cohorts, patients with Medicaid remained at increased risk for postoperative deep vein thrombosis (adjusted odds ratio [OR], 1.16; p = 0.031), pulmonary embolism (adjusted OR, 1.39; p < 0.001), periprosthetic joint infection (adjusted OR, 1.35; p < 0.001), and 90-day readmission (adjusted OR, 1.25; p < 0.001).

CONCLUSIONS

Patients with Medicaid were more likely to undergo TJA performed by lower-volume surgeons at lower-volume hospitals and had higher rates of postoperative complications compared with patients without Medicaid. Future research should assess socioeconomic status, insurance, and postoperative outcomes in this vulnerable patient population seeking arthroplasty care.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Controlled Hypotension Combined with Femoral Nerve Block for Knee Replacement without Tourniquet

In the process of knee replacement surgery, the use of tourniquet technology for hemostasis is the most common method. But the adverse reactions of tourniquets in knee replacement surgery have become more prominent in recent years. More and more scholars have begun to advocate the optimization of the use of tourniquet technology, thereby controlling the use of tourniquet technology. In this study, 125 patient cases were randomly divided into four experimental groups for comparative analysis. The two sets of variables are whether to use tourniquet during surgery and use intravenous analgesia or nerve block analgesia. Studies have shown that when using a tourniquet for knee replacement surgery, the chance of hidden blood loss increases after use. The tourniquet was not used during the operation, the patient's thighs were swollen, and postoperative pain was reduced. Compared with intravenous analgesia, knee joint replacement with uncontrolled tourniquet combined with femoral nerve block has a better analgesic effect and can effectively relieve pain after knee replacement. Therefore, under the method of controlled hypotension combined with femoral nerve block, TKA surgery without using tourniquet technology is more conducive to early health recovery and pain relief after TKA surgery, as well as functional exercise and knee joint recovery during postoperative recovery.

Total joint replacement surgeon choice: A qualitative analysis in a medicare population

INTRODUCTION

Previous research has shown that patients from historically marginalized groups in the United States tend to have poorer outcomes after joint replacement surgery and that they are less likely to receive joint replacement surgery at high-volume hospitals. However, little is known regarding how this group of patients chooses their joint replacement surgeon. The purpose of this study was to understand the factors influencing the choice of joint replacement surgeon amongst a diverse group of patients.

METHODS

Semi-structured interviews were conducted with Medicare patients who underwent a hip or knee replacement within the last 24 months (N = 38) at an academic and community hospital. Interviews were audio recorded, transcribed and verified for accuracy. Transcripts were reviewed using iterative content analysis to extract key themes related to how respondents chose their joint replacement surgeon.

RESULTS AND DISCUSSION

MD referral/recommendation appears to be the strongest factor influencing joint replacement surgeon choice. Other key considerations are hospital reputation and surgeon attributes-including operative experience, communication skills, and participation in shared decision-making. Gender/ethnicity of a surgeon, industry payments to surgeons, number of publications and cost did not play a large role in surgeon choice.

CONCLUSION AND CLINICAL RELEVANCE

The process of choosing a joint replacement surgeon is a complex decision-making process with several factors at play. Despite growing availability of information regarding surgeons, patients largely relied on referrals for choosing their joint replacement surgeon regardless of ethnicity. Referring physicians need to ensure that patients are able to access hospital and surgeon outcomes, operative volume, and industry-payment information to learn more about their orthopedic surgeons in order to make an informed choice.

Perspective of potential patients on the hospital volume-outcome relationship and the minimum volume threshold for total knee arthroplasty: a qualitative focus group and interview study

BACKGROUND

Total knee arthroplasty (TKA) is performed to treat end-stage knee osteoarthritis. In Germany, a minimum volume threshold of 50 TKAs/hospital/year was implemented to ensure outcome quality. This study, embedded within a systematic review, aimed to investigate the perspectives of potential TKA patients on the hospital volume-outcome relationship for TKA (higher volumes associated with better outcomes).

METHODS

A convenience sample of adults with knee problems and heterogeneous demographic characteristics participated in the study. Qualitative data were collected during a focus group prior to the systematic review (n = 5) and during telephone interviews, in which preliminary results of the systematic review were discussed (n = 16). The data were synthesised using content analysis.

RESULTS

All participants (n = 21) believed that a hospital volume-outcome relationship exists for TKA while recognising that patient behaviour or the surgeon could also influence outcomes. All participants would be willing to travel longer for better outcomes. Most interviewees would choose a hospital for TKA depending on reputation, recommendations, and service quality. However, some would also choose a hospital based on the results of the systematic review that showed slightly lower mortality/revision rates at higher-volume hospitals. Half of the interviewees supported raising the minimum volume threshold even if this were to increase travel time to receive TKA.

CONCLUSIONS

Potential patients believe that a hospital volume-outcome relationship exists for TKA. Hospital preference is based mainly on subjective factors, although some potential patients would consider scientific evidence when making their choice. Policy makers and physicians should consider the patient perspectives when deciding on minimum volume thresholds or recommending hospitals for TKA, respectively.

Factors Influencing Patient Selection of Urologists

OBJECTIVE

To describe the factors affecting patients' selection of a urologist, and the utilization of the Internet and social media.

MATERIALS AND METHODS

All new patients presenting to a single-institution for evaluation were invited to complete an anonymous 26-item questionnaire between April 2018 and October 2018, including demographic information, use of Internet and social media resources, and relative importance of factors when selecting a urologist. Descriptive statistics were reported, and a stratified analysis was performed for age, gender, and education.

RESULTS

A total of 238 patients responded. More than half (53%) of patients searched their medical condition prior to presentation. When stratified by age, younger patients were 3 times as likely to utilize Internet resources (Group 1 vs Group 2; OR 3.3, 95%CI 1.5-7.2, P <.01). Few patients utilized Facebook (7%) or Twitter (1%). The 3 most important surveyed urologist selection factors included hospital reputation (4.3 ± 1.0), in-network providers (4.0 ± 1.3), and appointment availability (3.9 ± 1.0). The 3 least important included medical school attended (2.7 ± 1.3), urologist on social media (1.9 ± 1.2), and TV, radio, and/or billboard advertisements (1.7 ± 1.3).

CONCLUSION

This study suggests a significant proportion of patients search the Internet regarding their medical condition prior to presenting to clinic. Further, younger patients utilize this methodology significantly more than the senior population. Important factors when selecting a urologist may be driven by a hospital's reputation, in addition to scheduling convenience.

Factors considered by patients in provider selection for elective specialty surgery: A questionnaire-based survey

BACKGROUND

This study was designed to comprehensively evaluate the factors considered by patients in provider selection for elective specialty surgery.

MATERIALS AND METHODS

A total of 200 patients (mean age 44.4 (range, 18.0-70.0) years, 51.0% were males), who were admitted to a tertiary care center for an elective surgery, participated on a voluntary basis in this cross-sectional questionnaire survey. The questionnaire form elicited items on sociodemographic characteristics of patients, characteristics of operation, factors contributing to physician selection by patients (physician-related factors, healthcare service/access related factors) and patients' view on factors contributing to physician selection.

RESULTS

Amongst the physician-related factors, attitude of physician (all items considered very important by majority of patients) was the factor most significantly contributed to physician selection as followed by reputation (recommendation of physician by former patients considered very important by 58.5%) or professional experience (presence of subspecialty certificate in surgery considered very important by 67.5%) and social media presence of the physician (comments and ratings of users about the physician considered very important by 26.5% of patients) of the physician. Patients considered hospital hygiene (75.5%) as the most significant healthcare service/access related factor in physician selection. Physician selection was considered to be of utmost importance in the treatment outcome by 95.5% of patients, while getting information about the physician before contacting her/him was considered important and actually performed for the current admission by 74% of patients.

CONCLUSION

In conclusion, our findings revealed that communicative skills of the physician, presence of subspecialty certificate in surgery, recommendations by former patients and comments and ratings of users were the leading factors contributed to physician selection by patients; being related to attitude, professional experience, reputation and social media presence of the physician, respectively. Hospital hygiene was the most significant healthcare service/access related factor contributed to physician selection.

Predicting Inpatient Dissatisfaction Following Total Joint Arthroplasty: An Analysis of 3,593 Hospital Consumer Assessment of Healthcare Providers and Systems Survey Responses

BACKGROUND

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, created by the Centers for Medicare and Medicaid, is directly tied to hospital reimbursement. The purpose of this study is to identify factors that are predictive HCAHPS survey responses following primary hip and knee arthroplasty.

METHODS

Prospectively collected HCAHPS responses from patients undergoing elective hip and knee arthroplasty between January 2013 and October 2017 at our institution were analyzed. Patient age, gender, race, marital status, body mass index, American Society of Anesthesiologists score, preoperative pain score, smoking status, alcohol use, illegal drug use, socioeconomic quartile, insurance type, procedure type, hospital type (academic vs community), distance to medical center, length of stay (LOS), and discharge disposition were obtained and correlated with HCAHPS inpatient satisfaction scores.

RESULTS

Responses from 3593 patients were obtained: 1546 total hip arthroplasties, 1899 total knee arthroplasties, and 148 unicompartmental knee arthroplasties. Mean overall HCAHPS score was 79.2. Women had lower inpatient satisfaction than men (77.6 vs 81.6, P < .001). Alcohol consumers had lower inpatient satisfaction than abstainers (77.7 vs 81.6, P < .001). Inpatient satisfaction varied by socioeconomic quartile (P < .001) with patients in the highest quartile having lower satisfaction than patients in all other quartiles (P < .001). Patients discharged to a facility had lower inpatient satisfaction than those discharged home (71.2 vs 80.2, P < .001). An inverse correlation between inpatient satisfaction and LOS (r = -0.19, P < .001) and a direct correlation between satisfaction and distance to medical center (r = 0.06, P < .001) were seen.

CONCLUSION

Patients more likely to report lower levels of inpatient satisfaction after total joint arthroplasty are female, affluent, and alcohol consumers, who are discharged to postacute care facilities. Inpatient satisfaction was inversely correlated with LOS and positively correlated with distance from patient home to medical center. These findings provide targets for improvements in TJA inpatient care.

Hospital choice in Germany from the patient's perspective: a cross-sectional study

Background

In many countries health policy encourages patients to choose their hospital, preferably by considering information of performance reports. Previous studies on hospital choice mainly have focused on patients undergoing elective surgery. This study examined a representative sample of hospital inpatients across disciplines and treatment interventions in Germany. Its research questions were: How many patients decide where to go for hospital treatment? How much time do patients have before admission? Which sources of information do they use, and which criteria are relevant to their decision?

Methods

Cross-sectional observational study covering 1925 inpatients of 46 departments at 17 hospitals in 2012. The stratified survey comprised 11 medical disciplines (internal medicine, gynaecology, obstetrics, paediatrics, psychiatry, orthopaedics, neurology, urology, ENT and geriatrics) on 3 hospital care levels representing 91.9% of all hospital admissions to inpatient care in Germany in 2012. The statistical analysis calculated the frequency distributions and 95% confidence intervals of characteristics related to the hospital choice.

Results

63.0% [60.9–65.2] of patients in Germany chose the hospital themselves, but only 21.1% [19.3–22.9] had more than one week to decide prior to admission. Major sources of information were personal knowledge of hospitals, relatives, outpatient health professionals and the Internet. Main criteria for the decision were personal experience with a hospital, recommendations from relatives and providers of outpatient services, a hospital’s reputation and distance from home. Specific quality information as provided by performance reports were of secondary importance.

Conclusions

A majority of patients in the German health system choose their hospital freely. Providers of outpatient health care can have an important “agent” function in the quality-oriented hospital choice especially for patients with little time prior to admission and those who do not decide themselves. Hospitals have an impact on patients’ future hospital choices by the treatment experience they provide to patients.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2712-3) contains supplementary material, which is available to authorized users.

The potential influence of regionalization strategies on delivery of care for elective total joint arthroplasty

Regionalization of total joint arthroplasty (TJA) to high volume hospitals (HVHs) may affect access to care and complication risk. Using administrative data, 2,560,314 patients who underwent primary total hip or knee arthroplasty from 1991 to 2006 were categorized by whether an HVH (>200 annual TJAs) was available locally. Associations among patient characteristics, hospital utilization, and in-hospital complications were estimated using regression modeling. The complication risk was higher (Odds Ratio 1.18 [95% CI: 1.16, 1.20]) if patients went to a local low volume hospital. Black and Medicaid patients were more likely to utilize the local low volume hospital than a local HVH. Utilizing a local HVH is associated with lower complication risks. However, patients from vulnerable groups were less likely to utilize these patterns.

Patients' expectations of variation in quality of care relates to their search for comparative performance information

Background

Choice of hospital based on comparative performance information (CPI) was introduced for Dutch healthcare consumers at least 5 years ago, but CPI use has not yet become commonplace. Our aim was to assess the role of patients’ expectations regarding variation in the quality of hospital care in determining whether they search for CPI.

Methods

A questionnaire (for a cross-sectional survey) was distributed to 475 orthopaedic patients in a consecutive sample, who underwent primary hip or knee replacement in a university, teaching, or community hospital between September 2009 and July 2010.

Results

Of the 302 patients (63%) who responded, 13% reported searching for CPI to help them choose a hospital. People who expected quality differences between hospitals (67%) were more likely to search for CPI (OR =3.18 [95% CI: 1.02–9.89]; p <0.04) than those who did not. Quality differences were most often expected in hospital reputation, distance, and accessibility. Patients who did not search for CPI stated that they felt no need for this type of information.

Conclusion

Patients’ expectations regarding variation in quality of care are positively related to their reported search for CPI. To increase the relevance of CPI for patients, future studies should explore the underlying reasoning of patients about meaningful quality-of-care variation between hospitals.

Is changing hospitals for revision total joint arthroplasty associated with more complications?

BACKGROUND

Many patients change hospitals for revision total joint arthroplasty (TJA). The implications of changing hospitals must be better understood to inform appropriate utilization strategies.

QUESTIONS/PURPOSES

(1) How frequently do patients change hospitals for revision TJA? (2) Which patient, community, and hospital characteristics are associated with changing hospitals? (3) Is there an increased complication risk after changing hospitals?

METHODS

We identified 17,018 patients who underwent primary TJA and subsequent same-joint revision in New York or California (1997-2005) from statewide databases. Medicare was the most common payer (56%) followed by private insurance (31%). We identified patients who changed hospitals for revision TJA and those who experienced in-hospital complications. Patient, community, and hospital characteristics were analyzed to determine predictors for changing hospitals for revision TJA and the effect of changing hospitals on subsequent complications.

RESULTS

Thirty percent of patients changed hospitals for revision. Older patients were less likely to change hospitals (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.73-0.96); no other patient characteristics were associated with changing hospitals. Patients who had index TJA at the highest-volume hospitals were less likely to change hospitals (OR, 0.52; 95% CI, 0.48-0.57). Overall, changing hospitals was associated with higher complication risk (OR, 1.19; 95% CI, 1.03-1.39). Changing to a lower-volume hospital (6% of patients undergoing revision TJA) was associated with a higher risk of complications (OR, 1.36; 95% CI, 1.05-1.74). A post hoc number needed-to-treat analysis indicates that 234 patients would need to be moved from a lower volume hospital to a higher volume hospital to avoid one overall complication event after revision TJA.

CONCLUSIONS

Although the complication risk was higher if changing hospitals, this finding was sensitive to the type of change. Our findings build on the existing evidence of a volume-outcomes benefit for revision TJA by examining the effect of volume in view of potential patient migration.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Recognition of physiotherapists' expertise in Parkinson's disease

BACKGROUND

Publicly available information comparing performance across quality and costs has proliferated in recent years, both about individual healthcare professionals and hospitals. This type of information is now becoming increasingly available for physiotherapists with expertise in Parkinson's disease (PD). Our study aimed to explore the ability of people with Parkinson's disease to recognise expertise, and to what extent respondents selectively choose such expert physiotherapists.

METHODS

We used claim data from the period 2009-2010 to select customers with PD who claimed physiotherapy. A random sample of 500 eligible respondents received a paper-based survey. We used descriptive statistics to compare the respondent characteristics, a qualitative programme to analyse the qualitative items, and univariate and multivariate regression.

RESULTS

Most respondents (89%) took their referring physician's advice when selecting a physiotherapist, although this advice rarely was supported with arguments. The remaining respondents (11%) searched for comparative performance information about physiotherapists. Respondents who recognised the added value of PD expertise among physiotherapists were 3.28 times as likely to search for comparative performance information as those who did not understand. Respondents were willing to switch to an expert physiotherapist (68%), and this willingness increased if they recognised the value of PD expertise (p < .001).

CONCLUSION

The participants were able to recognise certain aspects of expertise. Though they showed relatively few signs of selectively choice behaviour for expert physiotherapists. Both respondents and referring professionals need more understanding about the added value of an expert physiotherapist, to foster selective provider choice.

High survival of modular tapered stems for proximal femoral bone defects at 5 to 10 years followup

BACKGROUND

Currently, the two most commonly used options for the revision of femoral components in North America are: cylindrical, nonmodular, cobalt-chromium stems and tapered, fluted, modular, titanium (TFMT) stems. Previous reports have cited high failure rates with cylindrical cobalt chrome stems in large femoral defects but the longer term survival of the fluted stems is unknown.

QUESTIONS/PURPOSES

We examined the 5- to 10-year survival of TFMT stems implanted for severe femoral defects.

METHODS

We reviewed all 65 patients with severe proximal bone defects revised with the TMFT stem between January 2000 and 2006. Ten were lost to followup and seven were dead, leaving 48 patients for followup at 5 to 10 years (mean, 84 months; range, 60-120 months). All patients completed five quality-of-life (QOL) questionnaires. Radiographs were evaluated for loosening, subsidence, and preservation of proximal host bone stock.

RESULTS

Implant survivorship was 90%. No patient underwent revision for either subsidence or loosening. Subsidence occurred in seven patients (average, 12.3 mm) but all achieved secondary stability. Five patients underwent revision as a result of fracture of the stem and all had the original standard stem design, which has since been modified. All five implant fractures occurred at the modular stem junction. Mean QOL outcomes were: WOMAC = 81 (pain), Oxford = 75, SF-12 = 54 (mental) and 38 (physical), UCLA Activity = 4, and satisfaction overall = 73.

CONCLUSIONS

Midterm survivorship of modular titanium stems in large femoral defects is high; however, ongoing surveillance of stem junctional fatigue life is required.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Estimating proximity to care: are straight line and zipcode centroid distances acceptable proxy measures?

BACKGROUND

Spatial accessibility of healthcare may be measured by proximity of patient residence to health services, typically in driving distance or driving time. Precise driving distances and times are rarely available. Although straight line distances between zipcode centroids and between precise address locations are used as proxy measures for distance to care, the accuracy of these measures has received little study.

METHODS

Among a cohort of Medicare beneficiaries, actual driving distances and times between patient residence and clinic were obtained from commercial software (MapQuest). We used a split-sample design to build and validate linear regression models that predict actual driving distances and times from estimated distances between zipcode centroids and between precise residential and hospital locations, adjusting for urban/suburban/rural residential status.

RESULTS

On average, predicted driving distances and times were larger than actual values. Zipcode centroid distances alone predicted longer driving distances than observed values: rural +19% (3.2 miles), suburban +23% (3.7 miles), and urban +27% (2.0 miles). Predicted time was 36% (9.4 min) longer in rural, 32% (6.8 min) longer in suburban, and 38% (4.7 min) longer in urban areas than observed values. Including urban/suburban/rural categorization of residence improved the accuracy of predicted driving distance and time for suburban and urban areas but diminished accuracy for rural areas. Similar trends were observed for distance estimates from precise locations.

CONCLUSIONS

Distances between zipcode centroids and precise residential/hospital locations provide reasonable estimates of driving distance and time for epidemiologic research. Estimates are improved for suburban and urban residences when data are augmented by urban categorization.

Decision support needs of patients choosing between unicompartmental and total knee arthroplasty for advanced medial compartment osteoarthritis of the knee

Patients with isolated medial knee osteoarthritis are often candidates for both unicompartmental knee arthroplasty and total knee arthroplasty and must choose between these 2 options. We interviewed 20 such patients to describe their decision support needs and 14 knee arthroplasty surgeons to describe their requirements in supporting patients' decision making. Patients and surgeons both desired active patient participation in the decision. Of 14 surgeons, 13 identified a knowledgeable patient as the most important factor in facilitating decision making, but many worried about confusing patients from information overload. Patients, on the other hand, demonstrated poor knowledge of the advantages and disadvantages of each surgical option, and 17 of 20 desired supplemental educational resources. Thus, most patients choosing between unicompartmental knee arthroplasty and total knee arthroplasty would appreciate and benefit from a decision support intervention.

Patient choice systems and waiting times for scheduled services

Access to scheduled healthcare is a continuing challenge. A synthesis of the international literature was conducted to examine the potential of patient choice systems to reduce waiting times in Canada. A multitude of factors appear to influence the actions and outcomes of patients, providers, and systems. For choice systems to be effective, there must be uptake, which requires incentives and supports. Choice should be considered as but one element of a comprehensive waiting time management strategy.

Choosing a Hospital for Surgery: The Importance of Information on Quality of Care

Objective. To assess whether patients use information on quality of care when choosing a hospital for surgery compared with more general hospital information. Methods. In this cross-sectional study in 3 Dutch hospitals, questionnaires were sent to 2122 patients who underwent 1 of 6 elective surgical procedures in 2005—2006 (aorta reconstruction [for treatment of aneurysm], cholecystectomy, colon resection, inguinal hernia repair, esophageal resection, thyroid surgery). Patients were asked which information they had used to choose this hospital and which information they intended to use if they would need similar surgical treatment in the future. Results. In total, 1329 questionnaires were available for analysis (response rate 62.6%). Most patients indicated having used the hospital’s good reputation (69.1%) and friendly hospital atmosphere (63.3%) to choose a hospital. For future choices, most patients intended to use the fact that they were already treated in that hospital (79.3%) and the hospital’s good reputation (74.1%). Regarding quality-of-care information, patients preferred a summary measure (% patients with ‘‘textbook outcome’’) over separate more detailed measures (52.1% v. 38.0%, χ2 = 291, P < 0.01). For future choices, patients intend to use more information items than in 2005—2006, both in absolute terms (9 v. 4 items, t = 38.3, P < 0.01) as relative to the total number of available items (41.3% [40.1%—42.5%] v. 29.2% [28.1%—30.2%]). Conclusion. Patients intended to use more information for future choices than they used for past choices. For future choices, most patients prefer a summary measure on quality of care over more detailed measures but seem to value that they were already treated in that hospital or a hospital’s good reputation even more.

Adverse events after total knee arthroplasty: a national Medicare study

Adverse events from 2033 total knee arthroplasty patients were documented by nonphysician abstractors. The annual rate of adverse events from 2002 to 2004 was 9.2%, 6.4%, and 5.8%, respectively. Congestive heart failure (odds ratio, 2.1; 95% confidence interval, 1.2-3.5; P < .01) and chronic obstructive pulmonary disease (odds ratio, 1.8; 95% confidence interval, 1.2-2.7; P < .01) were associated with a significantly increased risk of experiencing any adverse event during the index hospitalization. The 30-day postprocedure rate of readmission for all causes was 5.5%. Experiencing an adverse event during the index hospitalization increased the length of stay (P < .001). The rate of symptomatic venous thromboembolism 30 days postprocedure was 1.7%. The 30-day postprocedure mortality rate was 0.3%. Experiencing any adverse event was associated with an increased 30-day postprocedure mortality (P < .001). Compared with previous studies of Medicare claims, these data reveal a substantial decrease in the mortality rate, an increased readmission rate, and no substantial change in the rate of venous thromboembolism.

Periacetabular osteotomy and total hip arthroplasty in patients older than 40 years

The objective of this study was to investigate quality of life (QOL) in patients with dysplasia who were older than 40 years and who underwent Bernese periacetabular osteotomy (PAO). Quality of life was compared among 28 patients who underwent PAO and 33 patients of the same age who underwent total hip arthroplasty (THA). Outcome tools included the Western Ontario McMasters Universities (WOMAC) Osteoarthritis Index and the 12-Item Short-Form Health Survey. Seventy-three percent of PAO patients achieved a "very good" (75-100) outcome or a "good" (65-75) QOL score in pain dimension and 64% in function dimension at 4 years after operation. WOMAC pain (89 vs 71, P < .005) and function (90 vs 74, P < .005) scores were significantly better among THA patients (THA vs PAO). Although THA resulted in better QOL, osteotomy still provided excellent QOL outcome in a high percentage of patients older than 40 years. However, given the results of this study, in patients older than 40 years, periacetabular osteotomy should only be done in highly selected cases.

Who, when, and why total joint replacement surgery? The patient's perspective

PURPOSE OF REVIEW

Although total joint replacement is an effective treatment for advanced arthritis, many whom might benefit are unwilling to consider this procedure. This review highlights advances in understanding of patients' perceptions of total joint replacement.

RECENT FINDINGS

Research shows that patients' willingness to consider total joint replacement varies by sex, race/ethnicity, and socioeconomic status as a result of systematic differences in knowledge and beliefs about the procedure. Individuals with low socioeconomic status and minorities view the procedure less favorably than their wealthier, white counterparts, possibly partly explaining disparity in rates of use of the procedure among these groups. Among those undergoing total joint replacement, up to 30% experience a suboptimal outcome or are dissatisfied with results. Early work suggests that patients' expectations and self-efficacy are important potential predictors of postoperative outcome. Patient information needs regarding total joint replacement vary significantly and possibly systematically by sex and race/ethnicity. Available information materials may not address the concerns of many individuals contemplating the procedure, posing a potential barrier to surgery.

SUMMARY

Targeted culturally sensitive knowledge dissemination strategies are needed to improve the knowledge and beliefs of people with hip/knee arthritis about total joint replacement.

Improved outcome in femoral revision arthroplasty with tapered fluted modular titanium stems

Many techniques have been advanced to achieve reliable femoral stem fixation in revision total hip arthroplasty. In a cross-sectional study, we compared quality of life in 220 patients with two femoral stem designs: a modular tapered and fluted titanium stem design and a cylindrical extensively coated chrome-cobalt stem with single modularity (head size and neck length alone). We matched cohorts based on age decade and gender. The minimum followup was 1 year with a median of 2 years. Subjective outcome assessment and patient satisfaction were measured using the WOMAC Osteoarthritis Index, the Oxford Hip Score, the SF-12, and the Arthroplasty Satisfaction Scale. At followup, all quality of life measures favored the tapered titanium stem. WOMAC pain, function, and overall scores all were higher in this group. The Oxford Hip Score and the Satisfaction score reflected a greater difference in outcome between the two stem designs. We presume reduced stiffness of the titanium stem, coupled with the intraoperative modularity, resulted in the improved patient outcomes observed in this study.