Association of Pain on Hospital Discharge with the Risk of 30-Day Readmission in Patients with Total Hip and Knee Replacement

Association between self-reported pain experiences in hospital and ratings of care, readmission and emergency department visits: a population-based study from New South Wales, Australia

INTRODUCTION

Evidence on patient experiences with pain in hospitals and its impact on post-discharge outcomes is limited. This study investigated the prevalence of pain in hospitals, patient characteristics associated with pain management adequacy, and the link between pain experiences, care ratings, readmission and emergency department visits after discharge.

METHODS

We conducted a retrospective cross-sectional analysis of the 2019 Adult Admitted Patient Survey, focusing on self-reported pain experiences, including presence, severity and management adequacy. The outcomes included self-reported overall care ratings; readmission; and emergency department visits within one month of discharge. Multivariable logistic regression adjusted for population weight was used to estimate adjusted odds ratios.

RESULTS

Among 75 large public hospitals, 21,900 patients responded (35% response rate), with 51% of patients reporting pain (mean (SD) age 57 (8.8) y; 54.9% female), 38.3% of whom classified their pain as severe. Aboriginal and/or Torres Strait Islander people and patients who spoke a language other than English were less likely to report adequate pain management (aOR (95%CI) 0.74 (0.58-0.96) and 0.82 (0.70-0.96), respectively). Pain also correlated with poor to very poor care ratings (aOR (95%CI) 2.05 (1.42-2.95)). Those patients who experienced pain were twice as likely to be readmitted (aOR (95%CI) 1.92 (1.55-2.37)) or visit the emergency department after discharge (aOR (95%CI) 1.91 (1.58-2.32)). Conversely, adequate pain management was associated with a lower likelihood of readmission (aOR (95%CI) 0.69 (0.51-0.94)) and emergency department visits (aOR (95%CI) 0.62 (0.44-0.87)). Mediation analysis suggests adequate pain management significantly mediated the relationship between pain severity and hospital rating (50.8%), readmission (11.6%) and emergency department visits (5.9%), after adjusting for all available observed confounders.

DISCUSSION

This study highlights the importance of adequate pain management in patients' perception of care and recovery outcomes, especially among culturally and linguistically diverse patients.

Racial and Ethnic Disparities in Primary Total Knee Arthroplasty Outcomes: A Systematic Review and Meta-Analysis of Two Decades of Research

Racial disparities in outcomes following total knee arthroplasty (TKA) remain persistent. This systematic review and meta-analysis aims to comprehensively synthesize data between 2000-2020. An electronic search of studies was performed on PubMed, SCOPUS, and the Cochrane Library databases from January 1, 2000, and December 31, 2020. Random effects models were used to report unadjusted and adjusted estimates for a comprehensive list of care outcomes in TKA. 63 studies met PRISMA criteria. Black patients report greater odds of in-hospital mortality (odds ratio [OR]: 1.37, 95% CI: 1.00-1.59 (p = 0.049); adjusted OR [aOR]: 1.34, 95% CI: 1.09-1.64), in-hospital complications (OR: 1.31, 95% CI: 1.27-1.35), 30-day complications (aOR: 1.19, 95% CI: 1.07-1.33), infection (OR: 1.11, 95% CI: 1.07-1.16; aOR: 1.30, 95% CI: 1.16-1.46), bleeding (OR: 1.33, 95% CI: 1.03-1.71; aOR: 1.47, 95% CI: 1.23-1.75), peripheral vascular events (PVE) (aOR: 1.46, 95% CI: 1.11-1.92), length of stay (LOS) (OR: 1.20, 95% CI: 1.08-1.34), extended-LOS (aOR: 1.89, 95% CI: 1.53-2.33), discharge disposition (OR: 1.59, 95% CI: 1.29-1.96; aOR: 1.96, 95% CI: 1.70-2.25), 30-day (OR: 1.20, 95% CI: 1.13-1.27; aOR: 1.17 95% CI: 1.09-1.26) and 90-day (OR: 1.46, 95% CI: 1.17-1.82) readmission compared to White patients. Disparities in bleeding, extended-LOS, discharge disposition, PVE, and 30-day readmission were observed in Asian patients. Hispanic patients experienced disparities in extended LOS and discharge disposition, while Native-American patients had disparities in bleeding outcomes. Persistent racial disparities in TKA outcomes highlight a need for standardized outcome measures and comprehensive data collection across multiple racial groups to ensure greater healthy equity.

Effects of different doses of dexmedetomidine combined with sufentanil in intravenous controlled analgesia after Salter osteotomy in children

Background

This study aimed to investigate the effect of different doses of dexmedetomidine combined with sufentanil on postoperative analgesia in developmental hip dislocation in children after Salter osteotomy.

Methods

The clinical data of 98 children with developmental hip dislocation, who underwent Salter osteotomy in our center between January 2020 and February 2023, were selected. The children were randomly divided into four groups based on the application of patient-controlled intravenous analgesia (sufentanil + granisetron ± dexmedetomidine). All children received 1 µg/kg/day of sufentanil and 3 mg of granisetron. Group A did not receive dexmedetomidine, and Groups B, C, and D received 0.5, 0.75, and 1.0 µg/kg/day of dexmedetomidine, respectively. The pain indicators and immune factor levels of children in each group were compared.

Results

The heart rate (HR) and respiratory rate (RR) 2 h after operation in Groups C and D were significantly lower than those in Groups A and B (P < 0.05). The pain scores decreased over time after treatment in all groups. When compared at the same time point, children in Group D had the lowest pain scores, which were significantly lower than the other three groups (P < 0.05). The total consumption of sufentanil in Groups C and D was significantly lower than that in Group A (P < 0.05). On the first day after surgery, the children in Group D had lower levels of serum adrenocorticotropic hormone, interleukin-6, and corticosterone than those in Group A (P < 0.05).

Conclusion

Administration of 1.0 µg/kg/day of dexmedetomidine combined with sufentanil in intravenous controlled analgesia after Salter osteotomy for developmental hip dislocation in children has a better analgesic effect, less consumption of sufentanil, and low incidence of opioid adverse reactions.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations

PURPOSE

Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways.

SOURCE

We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature.

PRINCIPAL FINDINGS

Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen.

CONCLUSION

Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

Can pain be improved with retention of the posterior cruciate ligament during total knee arthroplasty?

PURPOSE

The purpose of the current study was to determine if differences exist between cruciate-retaining (CR) and posterior-stabilized (PS) implant articulations for total knee arthroplasty (TKA) with regards to early post-operative pain.

METHODS

We retrospectively reviewed patients who underwent primary TKA, with the same TKA implant design, at our institution between January 2018 and July 2021. Patients were stratified based on whether they received a CR or non-constrained PS (PSnC) articulation and propensity score matched in a 1:1 ratio. A sub-analysis matching patient who received a constrained PS implant (PSC) to those undergoing CR TKA and PSnC TKA was also carried out. Opioid dosages were converted to morphine milligram equivalents (MME).

RESULTS

616 patients after CR TKA were matched 1:1 to 616 patients with a PSnC implant. There were no significant differences between demographic variables. There were no statistically significant differences in opioid usage measured by MME on post-operative day (POD) 0 (p = 0.171), POD1 (p = 0.839), POD2 (p = 0.307), or POD3 (p = 0.138); VAS pain scores (p = 0.175); or 90-day readmission rate for pain (p = 0.654). A sub-analysis of CR versus PSC TKA demonstrated no significant differences in opioid usage on POD0 (p = 0.765), POD1 (p = 0.747), POD2 (p = 0.564), POD3 (p = 0.309); VAS pain scores (p = 0.293); and 90-day readmission rate for pain (p > 0.9).

CONCLUSION

Our analysis demonstrated no significant difference in post-operative VAS pain scores and MME usage based on implant. The results suggest that neither the type of articulation or constraint used for primary TKA has a significant impact on immediate post-operative pain and opioid consumption.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Development of a patient-centred medication management model for polymedicated home-dwelling older adults after hospital discharge: results of a mixed methods study

OBJECTIVE

This study aimed to investigate medication management among polymedicated, home-dwelling older adults after discharge from a hospital centre in French-speaking Switzerland and then develop a model to optimise medication management and prevent adverse health outcomes associated with medication-related problems (MRPs).

DESIGN

Explanatory, sequential, mixed methods study based on detailed quantitative and qualitative findings reported previously.

SETTING

Hospital and community healthcare in the French-speaking part of Switzerland.

PARTICIPANTS

The quantitative strand retrospectively examined 3 years of hospital electronic patient records (n=53 690 hospitalisations of inpatients aged 65 years or older) to identify the different profiles of those at risk of 30-day hospital readmission and unplanned nursing home admission. The qualitative strand explored the perspectives of older adults (n=28), their informal caregivers (n=17) and healthcare professionals (n=13) on medication management after hospital discharge.

RESULTS

Quantitative results from older adults' profiles, affected by similar patient-related, medication-related and environment-related factors, were enhanced and supported by qualitative findings. The combined findings enabled us to design an interprofessional, collaborative medication management model to prevent MRPs among home-dwelling older adults after hospital discharge. The model comprised four interactive fields of action: listening to polymedicated home-dwelling older adults and their informal caregivers; involving older adults and their informal caregivers in shared, medication-related decision-making; empowering older adults and their informal caregivers for safe medication self-management; optimising collaborative medication management practices.

CONCLUSION

By linking the retrospective and prospective findings from our explanatory sequential study involving multiple stakeholders' perspectives, we created a deeper comprehension of the complexities and challenges of safe medication management among polymedicated, home-dwelling older adults after their discharge from hospital. We subsequently designed an innovative, collaborative, patient-centred model for optimising medication management and preventing MRPs in this population.

Characterization and Potential Relevance of Randomized Controlled Trial Patient Populations in Total Joint Arthroplasty in the United States: A Systematic Review

BACKGROUND

A substantial number of randomized controlled trial (RCT) studies in total joint arthroplasty (TJA) are published each year in the United States (US). However, it is unknown how closely the demographic and clinical characteristics of these cohorts resemble that of the US patient population undergoing TJA. Thus, the purpose of this systematic review was to evaluate the patient characteristics of published RCTs in TJA in the US and to compare these characteristics against patient cohorts from national patient databases.

METHODS

RCT studies regarding primary TJA conducted in the US were selected. Key patient demographics were aggregated and compared against demographics characteristics of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality National Inpatient Sample (NIS) and American College of Surgeons National Surgical Quality Improvement Program patient cohorts.

RESULTS

One hundred and fifty-three RCTs fulfilled the inclusion criteria and were included. The total number of patients in the 153 RCTs was 24,135 patients. The average age of patients in the TJA RCT cohort was 65 years (53-80) while the NIS cohort was 67 years (18-90) (d = 0.21, effect size = small). The average body mass index of the TJA RCT cohort was 30.8 (18.2-37.6) while the National Surgical Quality Improvement Program cohort was 31.9 (14.1-59.6) (d = 0.18, effect size = small). For TJA, effect sizes for age, body mass index BMI, sex, ethnicity, smoking, and diabetes were all small or very small.

CONCLUSION

Overall, the US RCT patient cohort for TJA does not differ substantially from the general patient population undergoing TJA in the United States. Differences in demographic and clinical characteristics between the TJA RCT cohort and database cohorts ranged from minimal to small, suggesting that these differences are unlikely to impact clinical outcomes.

Association of Occupational and Physical Therapy With Duration of Prescription Opioid Use After Hip or Knee Arthroplasty: A Retrospective Cohort Study of Medicare Enrollees

OBJECTIVE

To establish whether nonpharmacologic interventions, such as occupational and physical therapy, were associated with a shorter duration of prescription opioid use after hip or knee arthroplasty.

DESIGN

This retrospective cohort study used data from a national 5% Medicare sample database between January 1, 2010 and December 31, 2015.

SETTING

Home health or outpatient.

PARTICIPANTS

Adults 66 years or older with an inpatient total hip (n=4272) or knee (n=9796) arthroplasty (N=14,068).

INTERVENTIONS

We dichotomized patients according to whether they had received any nonpharmacologic pain intervention within 1 year after hospital discharge (eg, occupational or physical therapy evaluation). Using Cox proportional hazards, we treated exposure to nonpharmacologic interventions as time dependent to determine if skilled therapy was associated with duration of opioid use.

MAIN OUTCOME MEASURES

Duration of prescription opioid use.

RESULTS

Median time to begin nonpharmacologic interventions was 91 days (95% confidence interval [CI], 74-118d) for hip and 27 days (95% CI, 27-28d) for knee arthroplasty. Median time to discontinue prescription opioids was 16 days (hip: 95% CI, 15-16d) and 30 days (knee: 95% CI, 29-31d). Nonpharmacologic interventions delivered with home health increased the likelihood of discontinuing opioids after hip (hazard ratio [HR], 1.15; 95% CI, 1.01-1.30) and knee (HR, 1.10; 95% CI, 1.03-1.17) arthroplasty. A sensitivity analysis found these estimates to be robust and conservative.

CONCLUSIONS

Occupational and physical therapy with home health was associated with a shorter duration of prescription opioid use after hip and knee arthroplasty. Occupational and physical therapy can address pain and sociobehavioral factors associated with postsurgical opioid use.