Incidence, patterns and risk factors for readmission following knee arthroplasty in China: A national retrospective cohort study

Trends, risk factors, and complications of blood transfusion in primary total knee arthroplasty in China: a nationwide retrospective study

INTRODUCTION

Identifying risk factors and prognosis associated with red blood cell (RBC) transfusions will be meaningful in establishing effective blood management strategies. We aimed to examine the trends, risk factors, and complications of RBC transfusions in primary total knee arthroplasty (TKA) in China.

MATERIALS AND METHODS

The Hospital Quality Monitoring System was analyzed for patients undergoing primary TKA between 2013 and 2019. Trends in RBC transfusion rates, mean volume and cost were analyzed. Risk factors for transfusion were identified using multivariable logistic regression. After propensity score matching, the effects of transfusion on complications were examined using logistic regression, with the calculation of odds ratio (OR) and 95% confidence interval (CI).

RESULTS

A total of 11,894 transfused patients and 162,349 non-transfused patients were included. Transfusion rates substantially declined from 20.0% in 2013 to 3.0% in 2019 (P for trend < 0.001), accompanied by a continuous decrease in mean volume (3.9 unit [U] to 2.9 U, P for trend < 0.001) and cost (1,021.8 Chinese Yuan [CNY] to 811.1 CNY, P for trend < 0.001) of transfusion. Risk factors for transfusion included older age (OR 1.37; 95%CI 1.24-1.51), female sex (OR 1.30; 95%CI 1.23-1.35), non-osteoarthritis indication (OR 1.57; 95%CI 1.47-1.69), preoperative anemia (OR 3.76; 95%CI 3.11-4.55), higher Charlson Comorbidity Index score (OR 1.16; 95%CI 0.99-1.36), and hospitals in central (OR 1.47; 95%CI 1.41-1.53) and west (OR 1.41; 95%CI 1.34-1.49) regions. On propensity-adjusted analyses, transfusion was associated with higher risk of 30-day readmission (OR 1.25; 95%CI 1.07-1.47) and deep vein thrombosis (OR 1.49; 95%CI 1.22-1.83), and increased costs (66,845.39 vs. 61,263.56 CNY, P < 0.001).

CONCLUSIONS

Rates, volumes, and costs of RBC transfusion in TKA have fallen substantially in China. However, several risk factors for transfusion should be recognized and appropriately managed, as RBC transfusion increased complication rates and socioeconomic burden.

In-hospital complications and readmission patterns in 13,937 patients with developmental dysplasia of the hip undergoing total hip arthroplasty: Evidence from the Chinese national database

PURPOSE

Clarifying the prognosis and readmission patterns of patients with developmental dysplasia of the hip (DDH) following total hip arthroplasty (THA) would provide important references for clinical management for this population. Using the Chinese national inpatient database (i.e., Hospital Quality Monitoring System [HQMS]), we aimed to compare in-hospital complications and readmission patterns following THA in patients with DDH and primary osteoarthritis (OA).

METHODS

Patients undergoing THA for DDH and OA between 2013 and 2019 were identified using the HQMS. Demographics and clinical characteristics were compared between the two groups. After propensity score matching, in-hospital complications and readmission patterns were compared using a logistic regression model.

RESULTS

According to the analysis of 13,937 propensity-score matched pairs, there were no significant differences in the incidence of in-hospital death (0.01 % vs 0.04 %, P = 0.142), transfusion (8.09 % vs 7.89 %, P = 0.536), wound infection (0.31 % vs 0.25 %, P = 0.364), deep venous thrombosis (0.45 % vs 0.43 %, P = 0.786), pulmonary embolism (0.03 % vs 0.05 %, P = 0.372) or all-cause readmission (2.87 % vs 3.12 %, P = 0.219) between two groups. However, DDH patients had higher surgical readmission rates than OA patients (1.43 % vs 1.14 %, P = 0.033). When analyzing causes of surgical readmission, DDH patients had increased risk of dislocation (0.37 % vs 0.21 %, P = 0.011) and aseptic loosening (0.17 % vs 0.07 %, P = 0.024) than OA patients.

CONCLUSION

DDH patients had an increased risk of surgical readmission following THA, mainly driven by dislocation and aseptic loosening, which should be recognized and appropriately prevented.

Does a new case-based payment system promote the construction of the ordered health delivery system? Evidence from a pilot city in China

BACKGROUND

The construction of the ordered health delivery system in China aims to enhance equity and optimize the efficient use of medical resources by rationally allocating patients to different levels of medical institutions based on the severity of their condition. However, superior hospitals have been overcrowded, and primary healthcare facilities have been underutilized in recent years. China has developed a new case-based payment method called "Diagnostic Intervention Package" (DIP). The government is trying to use this economic lever to encourage medical institutions to actively assume treatment tasks consistent with their functional positioning and service capabilities.

METHODS

This study takes Tai'an, a DIP pilot city, as a case study and uses an interrupted time series analysis to analyze the impact of DIP reform on the case severity and service scope of medical institutions at different levels.

RESULTS

The results show that after the DIP reform, the proportion of patients receiving complicated procedures (tertiary hospitals: β3 = 0.197, P < 0.001; secondary hospitals: β3 = 0.132, P = 0.020) and the case mix index (tertiary hospitals: β3 = 0.022, P < 0.001; secondary hospitals: β3 = 0.008, P < 0.001) in tertiary and secondary hospitals increased, and the proportion of primary-DIP-groups cases decreased (tertiary hospitals: β3 = -0.290, P < 0.001; secondary hospitals: β3 = -1.200, P < 0.001), aligning with the anticipated policy objectives. However, the proportion of patients receiving complicated procedures (β3 = 0.186, P = 0.002) and the case mix index (β3 = 0.002, P < 0.001) in primary healthcare facilities increased after the reform, while the proportion of primary-DIP-groups cases (β3 = -0.515, P = 0.005) and primary-DIP-groups coverage (β3 = -2.011, P < 0.001) decreased, which will reduce the utilization efficiency of medical resources and increase inequity.

CONCLUSION

The DIP reform did not effectively promote the construction of the ordered health delivery system. Policymakers need to adjust economic incentives and implement restraint mechanisms to regulate the behavior of medical institutions.

Trends and benefits of early hip arthroplasty for femoral neck fracture in China: a national cohort study

BACKGROUND

Limited studies have examined the benefits of early arthroplasty within 48 h from admission to surgery for femoral neck fractures (FNFs). Using the national inpatient database, the authors aimed to investigate the trends in early arthroplasty within 48 h for FNFs in China and to assess its effect on in-hospital complications and 30-day readmission patterns.

MATERIALS AND METHODS

This was a retrospective cohort study. Patients receiving primary total hip arthroplasty (THA) or hemiarthroplasty (HA) for FNFs in the Hospital Quality Monitoring System between 2013 and 2019 were included. After adjusting for potential confounders with propensity score matching, a logistic regression model was performed to compare the differences in in-hospital complications [i.e. in-hospital death, pulmonary embolism, deep vein thrombosis (DVT), wound infection, and blood transfusion], rates and causes of 30-day readmission between early and delayed arthroplasty.

RESULTS

During the study period, the rate of early THA increased from 18.0 to 19.9%, and the rate of early HA increased from 14.7 to 18.4% ( P <0.001). After matching, 11 731 pairs receiving THA and 13 568 pairs receiving HA were included. Compared with delayed THA, early THA was associated with a lower risk of pulmonary embolism [odds ratio (OR) 0.51, 95% CI: 0.30-0.88], DVT (OR 0.59, 95% CI: 0.50-0.70), blood transfusion (OR 0.62, 95% CI: 0.55-0.70), 30-day readmission (OR 0.82, 95% CI: 0.70-0.95), and venous thromboembolism-related readmission (OR 0.50, 95% CI: 0.34-0.74). Similarly, early HA was associated with a lower risk of DVT (OR 0.70, 95% CI: 0.61-0.80) and blood transfusion (OR 0.74, 95% CI: 0.68-0.81) than delayed HA.

CONCLUSION

Despite a slight increase, the rate of early arthroplasty remained at a low level in China. Given that early arthroplasty can significantly improve prognosis, more efforts are needed to optimize the procedure and shorten the time to surgery.

Evaluation of risk factors for surgical site infections in osteoarthritis patients undergoing total knee arthroplasty

This research sought to delineate risk factors associated with surgical site infections (SSIs) post-total knee arthroplasty (post-TKA) in elderly osteoarthritis patients, aiming to enhance post-surgical outcomes. A retrospective examination was conducted on a cohort of 650 elderly patients who underwent unilateral TKA between January 2018 and August 2022. Data procurement was from the hospital's Electronic Health Record, and a comprehensive statistical evaluation was performed using IBM SPSS Statistics version 24.0. Both univariate and multivariate techniques assessed a spectrum of risk determinants such as age, body mass index (BMI), coexisting medical conditions and surgical variables. The univariate examination spotlighted age, BMI, diabetes prevalence, chronic corticosteroid consumption and American Society of Anesthesiologists (ASA) physical status classification as notable predictors of SSIs. The multivariate logistic regression pinpointed age, BMI, history of smoking and diabetes diagnosis as salient risk attributors for post-TKA infections. Concurrently, parameters like ASA classification, surgical duration and intraoperative haemorrhage further enriched the risk landscape. Geriatric patients undergoing TKA for knee osteoarthritis manifest a tangible infection susceptibility post-surgery. Precision interventions concentrating on amendable risk components, including meticulous preoperative evaluations and strategic postoperative care, are imperative to attenuate SSI incidence, thereby amplifying surgical efficacy and optimizing patient recuperation trajectories.

Trends, complications, and readmission of allogeneic red blood cell transfusion in primary total hip arthroplasty in china: a national retrospective cohort study

INTRODUCTION

Decrease in allogenic red blood cell (RBC) transfusion rates following total hip arthroplasty (THA) has been reported in the United States, but whether other countries share the same trend remains unclear. Additionally, the relation of allogenic RBC transfusion to the risk of complications in THA remains controversial. Using the Chinese national inpatient database, the current study aimed to examine trends, complications, charges, and readmission patterns of allogeneic RBC transfusion in THA.

MATERIALS AND METHODS

Patients undergoing primary THA between 2013 and 2019 were included, and then stratified into the transfusion and the non-transfusion group based on the database transfusion records. A generalized estimating equation model was used to investigate trends in transfusion rates. After propensity-score matching, a logistic regression model was used to compare the complications, rates and causes of 30-day readmission between two groups.

RESULTS

A total of 10,270 patients with transfusion and 123,476 patients without transfusion were included. Transfusion rates decreased from 19.11% in 2013 to 9.94% in 2019 (P for trend < 0.001). After matching, no significant differences in the risk of of in-hospital death (odds ratio [OR], 4.00; 95% confidence interval [CI] 0.85-18.83), wound infection (OR 0.72; 95%CI 0.45-1.17), myocardial infarction (OR 1.17; 95%CI 0.62-2.19), deep vein thrombosis (OR 1.25; 95%CI 0.88-1.78), pulmonary embolism (OR 2.25; 95%CI 0.98-5.17), readmission rates (OR 1.07; 95%CI 0.88-1.30) and readmission causes were observed between two groups. However, the transfusion group had higher hospitalization charges than the non-transfusion group (72,239.89 vs 65,649.57 Chinese yuan [CNY], P < 0.001).

CONCLUSIONS

This study found that allogeneic RBC transfusion in THA was not associated with the increased risk of complications and any-cause readmission. However, the currently restrictive transfusion policy should be continued because excessive blood transfusion may increase the socioeconomic burden.

Rural-urban differences in characteristics, postoperative outcomes, and costs for patients undergoing knee arthroplasty: a national retrospective propensity score matched cohort study

BACKGROUND

The rural-urban disparities in postoperative complications and costs among patients undergoing knee arthroplasty (KA) have not been thoroughly explored. This study aimed to determine whether such differences exist in this patient population.

MATERIAL AND METHODS

The study was conducted using data from the national Hospital Quality Monitoring System of China. Hospitalized patients undergoing KA from 2013 to 2019 were enrolled. Patient and hospital characteristics were compared between rural and urban patients, and differences in postoperative complications, readmissions, and hospitalization costs were analyzed using propensity score matching.

RESULTS

Of the 146 877 KA cases analyzed, 71.4% (104 920) were urban patients and 28.6% (41 957) were rural patients. Rural patients tended to be younger (64.4±7.7 years vs. 68.0±8.0 years; P <0.001) and had fewer comorbidities. In the matched cohort of 36 482 participants per group, rural patients were found to be more likely to experience deep vein thrombosis (OR: 1.31, 95% CI: 1.17-1.46; P <0.001) and require red blood cell (RBC) transfusion (OR: 1.38, 95% CI: 1.31-1.46; P <0.001). However, they had a lower incidence of readmission within 30 days (OR: 0.65, 95% CI: 0.59-0.72; P <0.001) and readmission within 90 days (OR: 0.61, 95% CI: 0.57-0.66; P <0.001) than their urban counterparts. In addition, rural patients incurred lower hospitalization costs than urban patients (57 396.2 Chinese Yuan vs. 60 844.3 Chinese Yuan; P <0.001).

CONCLUSION

Rural KA patients had different clinical characteristics compared with urban patients. While they had a higher likelihood of deep vein thrombosis and RBC transfusion following KA than urban patients, they had fewer readmissions and lower hospitalization costs. Targeted clinical management strategies are needed for rural patients.

Ultrasound-triggered in situ gelation with ROS-controlled drug release for cartilage repair

Cartilage defects are usually caused by acute trauma and chronic degeneration. However, it is still a great challenge to improve the repair of articular cartilage defects due to the limited self-regeneration capacity of such defects. Herein, a novel ROS-responsive in situ nanocomposite hydrogel loaded with kartogenin (KGN) and bone marrow-derived stem cells (BMSCs) was designed and constructed via the enzymatic reaction of fibrinogen and thrombin. Meanwhile, a ROS-responsive thioketal (TK)-based liposome was synthesized to load the chondrogenesis-inducing factor KGN, the bioenzyme thrombin and an ultrasound-sensitive agent PpIX. Under ultrasound stimulation, the TK-based liposome was destroyed, followed by in situ gelation of fibrinogen and thrombin. Moreover, sustained release of KGN was realized by regulating the ultrasound conditions. Importantly, ROS generation and KGN release within the microenvironment of the in situ fibrin hydrogel significantly promoted chondrogenic differentiation of BMSCs via the Smad5/mTOR signalling pathway and effectively improved cartilage regeneration in a rat articular cartilage defect model. Overall, the novel in situ nanocomposite hydrogel with ROS-controlled drug release has great potential for efficient cartilage repair.

Burden and Characteristics of Revision Total Knee Arthroplasty in China: a National Study Based on Hospitalized Cases

BACKGROUND

National epidemiological data in China are absent for revision total knee arthroplasty (TKA). This study aimed to investigate the burden and characteristics of revision TKA in China.

METHODS

We reviewed 4,503 revision TKA cases registered in the Hospital Quality Monitoring System in China between 2013 and 2018 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Revision burden was determined by the ratio of the number of revision procedures to the total number of TKA procedures. Demographic characteristics, hospital characteristics, and hospitalization charges were identified.

RESULTS

The revision TKA cases accounted for 2.4% of all TKA cases. The revision burden showed an increasing trend from 2013 to 2018 (2.3 to 2.5%) (P for trend = 0.034). Gradual increases in revision TKA were observed in patients aged > 60 years. The most common causes for revision TKA were infection (33.0%) and mechanical failure (19.5%). More than 70% of the patients were hospitalized in provincial hospitals. A total of 17.6% patients were hospitalized in a hospital outside the province of their residence. The hospitalization charges continued to increase between 2013 and 2015 and remained roughly stable over the next three years.

CONCLUSIONS

This study provided epidemiological data for revision TKA in China based on a national database. There was a growing trend of revision burden during the study period. The focalized nature of operations in a few higher volume regions was observed and many patients had to travel to obtain their revision procedure.