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Zhang Q, Chen Y, Li Y, Liu R, Rai S, Li J, Hong P. Enhanced recovery after surgery in patients after hip and knee arthroplasty: a systematic review and meta-analysis. Postgrad Med J 2024; 100:159-173. [PMID: 38134323 DOI: 10.1093/postmj/qgad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/01/2023] [Accepted: 11/10/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) was characterized as patient-centered, evidence-based, multidisciplinary team-developed routes for a surgical speciality and institution to improve postoperative recovery and attenuate the surgical stress response. However, evidence of their effectiveness in osteoarthroplasty remains sparse. This study aimed to develop an ERAS standard and evaluate the significance of ERAS interventions for postoperative outcomes after primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS We searched Medline, Embase, Cochrane databases, and Clinicaltrials.gov for randomized controlled trials, cohort studies, and case-control studies until 24 February 2023. All relevant data were collected from studies meeting the inclusion criteria. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was the length of stay (LOS), postoperative complications, and readmission rate. The secondary outcomes included transfusion rate, mortality rate, visual analog score (VAS), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Short Form 36 (SF-36) bodily pain (SF-36 BP), SF-36 physical function (SF-36 PF), oxford knee score, and range of motion (ROM). RESULTS A total of 47 studies involving 76 971 patients (ERAS group: 29 702, control group: 47 269) met the inclusion criteria and were included in the meta-analysis. The result showed that ERAS could significantly shorten the LOS (WMD = -2.65, P < .001), reduce transfusion rate (OR = 0.40, P < .001), and lower 30-day postoperative mortality (OR = 0.46, P = .01) without increasing postoperative complications or readmission rate. Apart from that, ERAS may decrease patients' VAS (WMD = -0.88, P = .01) while improving their ROM (WMD = 6.65, P = .004), SF-36 BP (WMD = 4.49, P < .001), and SF-36 PF (WMD = 3.64, P < .001) scores. However, there was no significant difference in WOMAC, oxford knee score between the ERAS and control groups.Furthermore, we determined that the following seven components of the ERAS program are highly advised: avoid bowel preparation, PONV prophylaxis, standardized anesthesia, use of local anesthetics for infiltration analgesia and nerve blocks, tranexamic acid, prevent hypothermia, and early mobilization. CONCLUSION Our meta-analysis suggested that the ERAS could significantly shorten the LOS, reduce transfusion rate, and lower 30-day postoperative mortality without increasing postoperative complications or readmission rate after THA and TKA. Meanwhile, ERAS could decrease the VAS of patients while improving their ROM, SF-36 BP, and SF-36 PF scores. Finally, we expect future studies to utilize the seven ERAS elements proposed in our meta-analysis to prevent increased readmission rate for patients with THA or TKA.
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Affiliation(s)
- Qingqing Zhang
- Department of Gastroenterology, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital, Wuhan 430022, China
| | - Yuzhang Chen
- Department of Endocrinology, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital,, Wuhan 430022, China
| | - Yi Li
- First Clinical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ruikang Liu
- Department of Endocrinology, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital, , Wuhan 430022, China
| | - Saroj Rai
- Department of Orthopedics, Al Ahalia Hospital Mussafah, Abu Dhabi 00000, United Arab Emirates
| | - Jin Li
- Department of Orthopaedic Surgery, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital, Wuhan 430022, China
| | - Pan Hong
- Department of Orthopaedic Surgery, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital, Wuhan 430022, China
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Berkovic D, Vallance P, Harris IA, Naylor JM, Lewis PL, de Steiger R, Buchbinder R, Ademi Z, Soh SE, Ackerman IN. A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection. BMC Med 2023; 21:511. [PMID: 38129857 PMCID: PMC10740291 DOI: 10.1186/s12916-023-03219-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection. METHODS A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed. RESULTS Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12-7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27-11.36); neurovascular injury (OR 0.31, 95% CI 0.01-7.92); other complications (OR 0.63, 95% CI 0.26-1.53); or stiffness (OR 1.04, 95% CI 0.53-2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814). CONCLUSIONS There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.
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Affiliation(s)
- Danielle Berkovic
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Patrick Vallance
- Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Kensington, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Justine M Naylor
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Kensington, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
| | - Peter L Lewis
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia and Faculty of Medicine, University of Adelaide, Adelaide, Australia
| | - Richard de Steiger
- Department of Surgery, Epworth HealthCare, University of Melbourne, Melbourne, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Health Economics and Policy Evaluation Research (HEPER), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Sze-Ee Soh
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Ilana N Ackerman
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
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Salamanna F, Contartese D, Brogini S, Visani A, Martikos K, Griffoni C, Ricci A, Gasbarrini A, Fini M. Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review. J Clin Med 2022; 11:4222. [PMID: 35887986 PMCID: PMC9322698 DOI: 10.3390/jcm11144222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.
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Affiliation(s)
- Francesca Salamanna
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Deyanira Contartese
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Silvia Brogini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Andrea Visani
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Konstantinos Martikos
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Cristiana Griffoni
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Alessandro Ricci
- Anesthesia-Resuscitation and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Alessandro Gasbarrini
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Milena Fini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
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Wilson E, Vala A, O'Callaghan J, McCann P, Al-Hourani K. The Effect of Simple Cost Effective Interventions in Improving Enhanced Recovery in Neck of Femur Fracture Care. Cureus 2020; 12:e11217. [PMID: 33133805 PMCID: PMC7594660 DOI: 10.7759/cureus.11217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Aim Due to the frequency and high mortality and morbidity associated with neck of femur fractures, pathways of care have been established in the United Kingdom. These include the Enhanced Recovery Program (ERP), which aims to maximise the quality of care whilst reducing their length of stay, and the Best Practice Tariff (BPT) which if adhered to warrants £1335 per neck of femur fracture. We conducted a prospective audit to assess adherence to these pathways in a trauma unit. Methods An audit was carried out between November 2015 and May 2016. The information was obtained from neck of femur fracture proformas, anaesthetic charts and drug charts by two investigators. Results Nine out of the 10 ERP components were adhered to in all 31 patients. This highlighted a deficiency in requesting day one post-operative osteoporosis bloods, which was only carried out in 61.3% of patients. As an intervention, a reminder sticker was placed on the operation note as an intervention. Re-audit following the introduction of the stickers showed a marked improvement of 90%. During the initial admission 38.7% of patients adhered to the BPT. The main area for improvement was fracture prevention assessment, specifically Fracture Risk Assessment Tool (FRAX) scores and Nottingham Hip Fracture Scores. To improve this these sections were highlighted in the proformas to promote their importance. Additionally, a smartphone application was made available to doctors to aid with ease of calculation. Following these interventions, 93% of patients had this data entered, with an improvement in overall tariff attainment to 63.3%. Conclusions The introduction of simple measures is beneficial both for patient safety and economically for hospitals.
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Affiliation(s)
| | - Arta Vala
- Trauma and Orthopaedics, Bristol Royal Infirmary, Bristol, GBR
| | | | - Philip McCann
- Trauma and Orthopaedics, Bristol Royal Infirmary, Bristol, GBR
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Nunns M, Shaw L, Briscoe S, Thompson Coon J, Hemsley A, McGrath JS, Lovegrove CJ, Thomas D, Anderson R. Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundElective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.ObjectivesTo evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.Data sourcesSeven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.Review methodsComparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.FindingsA total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.LimitationsStudies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.ConclusionsEnhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.Future workFurther studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.Study registrationThis study is registered as PROSPERO CRD42017080637.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Michael Nunns
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - John S McGrath
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Christopher J Lovegrove
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
- School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK
| | - David Thomas
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Anderson
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
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Abstract
STUDY DESIGN The enhanced perioperative care (EPOC) program is an institutional quality improvement initiative. We used a historically controlled study design to evaluate patients who underwent major spine surgery before and after the implementation of the EPOC program. OBJECTIVE To determine whether multidisciplinary EPOC program was associated with an improvement in clinical and financial outcomes for elective adult major spine surgery patients. SUMMARY OF BACKGROUND DATA The enhanced recovery after surgery (ERAS) programs successfully implemented in hip and knee replacement surgeries, and improved clinical outcomes and patient satisfaction. METHODS We compared 183 subjects in traditional care (TRDC) group to 267 intervention period (EPOC) in a single academic quaternary spine surgery referral center. One hundred eight subjects in no pathway (NOPW) care group was also examined to exclude if the observed changes between the EPOC and TRDC groups might be due to concurrent changes in practice or population over the same time period. Our primary outcome variables were hospital and intensive care unit lengths of stay and the secondary outcomes were postoperative complications, 30-day hospital readmission and cost. RESULTS In this highly complex patient population, we observed a reduction in mean hospital length of stay (HLOS) between TRDC versus EPOC groups (8.2 vs. 6.1 d, standard deviation [SD] = 6.3 vs. 3.6, P < 0.001) and intensive care unit length of stay (ILOS) (3.1 vs. 1.9 d, SD = 4.7 vs. 1.4, P = 0.01). The number (rate) of postoperative intensive care unit (ICU) admissions was higher for the TRDC n = 109 (60%) than the EPOC n = 129 (48%) (P = 0.02). There was no difference in postoperative complications and 30-day hospital readmissions. The EPOC spine program was associated with significant average cost reduction-$62,429 to $53,355 (P < 0.00). CONCLUSION The EPOC program has made a clinically relevant contribution to institutional efforts to improve patient outcomes and value. We observed a reduction in HLOS, ILOS, costs, and variability. LEVEL OF EVIDENCE 3.
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Marshall R, Pomeroy E, McKendry C, Gilmartin M, McQuail P, Johnson M. Anaesthesia for total hip and knee replacement: A review of patient education materials available online. F1000Res 2019; 8:416. [PMID: 33335711 PMCID: PMC7722535 DOI: 10.12688/f1000research.18675.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2019] [Indexed: 12/02/2022] Open
Abstract
Background: Patients frequently consult the internet for health information. Our aim was to perform an Internet-based readability and quality control study using recognised quality scoring systems to assess the patient information available online relating to anaesthesia for total hip and knee replacement surgery. Methods: Online patient information relating to anaesthesia for total hip and knee replacement was identified using Google, Bing and Yahoo with search terms
‘hip replacement anaesthetic’,
‘knee replacement anaesthetic.’ Readability was assessed using Flesch Reading Ease (FRE), Flesch-Kincaid grade level (FKGL) and Gunning Fog Index (GFI). Quality was assessed using DISCERN instrument, Health On the Net Foundation seal, and Information Standard mark. Results: 32 websites were analysed. 25% were HONcode certified, 15.6% had the Information Standard. Mean FRE was 55.2±12.8. Mean FKGL was 8.6±1.9. Six websites (18.8%) had the recommended 6
th-grade readability level. Mean of 10.4±2.6 years of formal education was required to read the websites. Websites with Information Standard were easier to read: FKGL (6.2 vs. 9,
P < 0.001), GFI (8.8 vs. 10.7,
P = 0.04), FRE score (64.2 vs. 9,
P = 0.02). Mean DISCERN score was low: 40.3 ± 13. Conclusions: Overall, most websites were poor quality with reading levels too high for the target audience. Information Standard NHS quality mark was associated with improved readability, however along with HONcode were not found to have a statistically significant correlation with quality. Based on this study, we would encourage healthcare professionals to be judicious in the websites they recommend to patients, and to consider both the readability and quality of the information provided.
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Affiliation(s)
- Rebecca Marshall
- Department of Anaesthesia, University Hospital Galway, Galway, Connaght, H91 YR71, Ireland
| | - Eoghan Pomeroy
- Department of Orthopaedics, Mater Misericordiae University Hospital, Dublin, Dublin, Ireland
| | - Catriona McKendry
- Department of Orthopaedics, Mater Misericordiae University Hospital, Dublin, Dublin, Ireland
| | - Michael Gilmartin
- Department of Orthopaedics, Mater Misericordiae University Hospital, Dublin, Dublin, Ireland
| | - Paula McQuail
- Department of Orthopaedics, St. James's Hospital, Dublin, Dublin, Ireland
| | - Mark Johnson
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Anaesthesia, Fiona Stanley Hospital, Murdoch, Australia
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Deng QF, Gu HY, Peng WY, Zhang Q, Huang ZD, Zhang C, Yu YX. Impact of enhanced recovery after surgery on postoperative recovery after joint arthroplasty: results from a systematic review and meta-analysis. Postgrad Med J 2018; 94:678-693. [PMID: 30665908 DOI: 10.1136/postgradmedj-2018-136166] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/07/2018] [Accepted: 12/01/2018] [Indexed: 12/22/2022]
Abstract
STUDY DESIGN Systematic review with meta-analysis. OBJECTIVES To evaluate the effects of enhanced recovery after surgery (ERAS) on the postoperative recovery of patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS The PubMed, Embase, Cochrane and ISI Web of Science databases were searched to identify literature including randomised controlled trials (RCTs), cohort studies and case-control studies through 2 May 2018. The analysed outcomes were mortality rate, transfusion rate, range of motion (ROM), 30-day readmission rate, postoperative complication rate and in-hospital length of stay (LOS). RESULTS A total of 25 studies involving 16 699 patients met the inclusion criteria and were included in the meta-analysis. Compared with conventional care, ERAS was associated with a significant decrease in mortality rate (relative risk (RR) 0.48, 95% CI 0.27 to 0.85), transfusion rate (RR 0.43, 95% CI 0.37 to 0.51), complication rate (RR 0.74, 95% CI 0.62 to 0.87) and LOS (mean difference (MD) -2.03, 95% CI -2.64 to -1.42) among all included trials. However, no significant difference was found in ROM (MD 7.53, 95% CI -2.16 to 17.23) and 30-day readmission rate (RR 0.86, 95% CI 0.56 to 1.30). There was no significant difference in complications of TKA (RR 0.84, 95% CI 0.34 to 2.06) and transfusion rate in RCTs (RR 0.66, 95% CI 0.15 to 2.88) between the ERAS group and the control group. CONCLUSIONS This meta-analysis showed that ERAS significantly reduced the mortality rate, transfusion rate, incidence of complications and LOS of patients undergoing TKA or THA. However, ERAS did not show a significant impact on ROM and 30-day readmission rate. Complications after hip replacement are less than those of knee replacement, and the young patients recover better. LEVEL OF EVIDENCE Level 1.
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Affiliation(s)
- Qi-Feng Deng
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Hui-Yun Gu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Wu-Ya Peng
- Department of Orthopedics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Qiong Zhang
- Department of Orthopedics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Zheng-Dong Huang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yun-Xiang Yu
- Department of Orthopedics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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Pang W, Chois JM, Lambie D, Lin RMH, Shih ZM. Experience of Immediate Ambulation and Early Discharge After Tumescent Anesthesia and Propofol Infusion in Cosmetic Breast Augmentation. Aesthetic Plast Surg 2017; 41:1318-1324. [PMID: 28707024 DOI: 10.1007/s00266-017-0929-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/20/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Current cosmetic breast augmentation relies on general anesthesia that normally requires 40 min to total recovery. With experience, the surgical procedure can be completed expediently in 20 min under tumescent anesthesia and propofol full sedation to achieve immediate postoperative ambulation and home discharge readiness, and thus improve patient satisfaction and reduce cost. We retrospectively examined the outcomes of the protocol. MATERIALS AND METHODS Per protocol, 1200 female patients underwent simple cosmetic breast augmentation accomplished with tumescent anesthesia, immediate mobilization, and early home discharge readiness after surgery. The following records were analyzed: vital sign stability during mobilization in the first 30 cases (primary goal), duration of surgery and anesthesia, frequency of intraoperative opioid use, frequency of ambulation needing assistance, Verbal Analog Scores and incidences of pain, orthostatic intolerance events, incidences of postoperative nausea and vomiting or anti-emetic use, and complications at follow-up visits (secondary goal). RESULTS Hemodynamics during immediate postoperative mobilization demonstrated no statistically significant fluctuations and/or orthostatic intolerance requiring interventions. The mean duration of surgery was 20.4 ± 4.1 min. The mean duration of anesthesia was 25.2 ± 6.8 min. All patients tolerated immediate postoperative ambulation well. Adverse postoperative events were scarce. Only 9.1% reported postoperative pain, and 5.7% reported postoperative nausea and vomiting. One percent had transit post-ambulation dizziness needing supine positioning for less than 3 min. The average time to meet home-readiness criteria was 4.7 min, and there was no incidence of hematoma, infection, or complaints at follow-ups. CONCLUSIONS For simple cosmetic breast augmentation, instead of general anesthesia and 40 min of recovery time, a tumescent anesthetic technique can be used for immediate postoperative ambulation and a 4.7-min home discharge readiness without a decrease in anesthesia quality and safety. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Weiwu Pang
- Advanced Aesthetics Surgery Center, 7425 Conroy Rd., Orlando, FL, 32835, USA
- Department of Anesthesiology, Wuri Lin Shin Hospital, No.168, Rong-he Rd. Wuri Dist., Taichung, 41454, Taiwan, ROC
| | - John M Chois
- Advanced Aesthetics Surgery Center, 7425 Conroy Rd., Orlando, FL, 32835, USA
| | - Diana Lambie
- Advanced Aesthetics Surgery Center, 7425 Conroy Rd., Orlando, FL, 32835, USA
| | - Richard Ming-Hui Lin
- Department Head of Emergency and Critical Care Medicine, Lin Shin Hospital, No.36, Sec. 3, Hueijhong Rd. Nantun Dist, Taichung City, 40867, Taiwan, ROC
| | - Zao-Ming Shih
- Department of Emergency and Critical Care Medicine, Wuri Lin Shin Hospital, No.168, Rong-he Rd. Wuri Dist., Taichung, 41454, Taiwan, ROC.
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