Thirty-day readmissions and reoperations after total elbow arthroplasty: a national database study

Impact of the hospital frailty risk score on outcomes following primary total elbow arthroplasty

BACKGROUND

The Hospital Frailty Risk Score (HFRS) has demonstrated strong correlation with adverse outcomes in various joint replacement surgeries, yet its applicability in total elbow arthroplasty (TEA) remains unexplored. The purpose of this study is to assess the association between HFRS and postoperative complications following elective primary TEA.

METHODS

The Nationwide Readmissions Database was queried to identify patients undergoing primary TEA from 2016-2020. The HFRS was used to compare medical, surgical, and clinical outcomes of frail vs. nonfrail patients. Mean and relative costs, total hospital length of stay, and discharge disposition for frail and nonfrail patients were also compared.

RESULTS

We identified 2049 primary TEA in frail patients and 3693 in nonfrail patients. Frail patients had increased complication rates including acute respiratory failure (13.6% vs. 1.1%; P < .001), urinary tract infections (12.3% vs. 0.0%; P < .001), transfusions (3.9% vs. 1.1%; P < .001), pneumonia (1.1% vs. 0.2%; P < .001), acute respiratory distress syndrome (3.2% vs. 0.6%; P < .001), sepsis (0.7% vs. 0.1%; P < .001), and hardware failure (1.2% vs. 0.1%; P < .001). Frail patients also experienced higher rates of readmission (37% vs. 25%; P < .001) and death (1.7% vs. 0.2%; P < .001), while being less likely to undergo revision (6.5% vs. 17%; P < .001). Frail patients incurred higher health-care costs ($28,497 vs. $23,377; P < .001) and longer length of stay (5.3 days vs. 2.6 days; P < .001), with reduced likelihood of routine hospital stays (36% vs. 71%; P < .001) and increased utilization of short-term hospitalization (P < .001), care facilities (P < .001), and home health-care services (P < .001).

CONCLUSION

HFRS is a validated indicator of frailty and is strongly associated with increased rates of complications in patients undergoing elective primary TEA. These findings should be considered by orthopedic surgeons when assessing surgical candidacy and discussing treatment options in this at-risk patient population.

Short-term adverse event rates and risk factors following total elbow arthroplasty for fracture and arthropathy: a matched analysis of nationally representative data

BACKGROUND

Total elbow arthroplasty (TEA) is a mainstay treatment for elbow arthropathy and elbow fracture that can relieve pain and restore functional motion. The purpose of this study was to determine the role of surgical indication in the incidence of short-term adverse events and risk factors influencing complications in TEA to treat arthropathy compared to TEA for fracture. Matched cohorts were created to better isolate the impact of the surgical indication.

METHODS

The study identified patients within the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database that underwent TEA to treat arthropathy or fracture from 2010 to 2020. Matched cohorts were created to analyze the incidence of 30 day adverse events and risk factors for complications.

RESULTS

The study included 599 patients for analysis. The overall incidence of any adverse event was 9.7%. In matched cohorts of 218 patients, the fracture group experienced a higher incidence of overall adverse events (13.8% vs. 6.0% in the arthropathy group, p = 0.009) and postoperative transfusions (9.6% vs. 1.8% in the arthropathy group, p < 0.001). Logistic regression revealed an increased risk of any adverse event in the combined matched cohort with longer operative times (OR = 1.007, CI: 1.002-1.012, p = 0.006) and those undergoing fracture treatment (OR = 2.447, CI: 1.047-5.717, p = 0.039). Outpatient status was associated with a lower risk of adverse events in the combined matched cohort (OR = 0.207, CI: 0.058-0.739, p = 0.015).

CONCLUSIONS

Even when controlling for comorbidities, patients undergoing TEA for fracture have a greater likelihood of short-term complications, particularly requiring a blood transfusion. Treatment of a fracture and increased operative time were risk factors for all patients, while outpatient status was protective.

LEVEL OF EVIDENCE

III.

Sex Disparities Affecting Postoperative Outcomes After Total Elbow Arthroplasty

Purpose

To investigate sex disparities in 30-day postoperative outcomes of total elbow arthroplasty.

Methods

The American College of Surgeons-National Surgical Quality Improvement Program files were queried for all patients who underwent a total elbow arthroplasty (TEA) between 2006 and 2020. Sex disparities in preoperative variables were studied using Fisher exact tests. Multivariate logistic regression models were used to determine the adjusted odds ratios (aOR) of postoperative outcomes for women in comparison with men.

Results

A total of 788 patients underwent a TEA in the period of 2006-2020. Of those, 180 were men, and 608 were women. We found an increase in TEAs performed each year with a predominance in females compared to males. Additionally, our work demonstrated increased statistically significant odds of a major adverse cardiac event (P < .0001), transfusions required (P < .0001), and return to the operating room (P < .0001) as postoperative outcomes in females compared to males following TEA. Finally, we found no statistically significant difference in mortality between the groups (P = 1).

Conclusions

Following a TEA, women had higher adjusted postoperative odds of experiencing a major adverse cardiac event, requiring transfusion, and return to the operating room. No significant differences were found in wound outcomes, pulmonary outcomes, venous thromboembolic outcomes, sepsis, and length of stay. Overall mortality rates were similar between the two groups. Our study warrants further evaluation of the root cause of sex disparities in TEA outcomes and methods to improve care delivery to reduce those disparities.

Type of study/level of evidence

Prognostic 2b.

The Risk of Early Postoperative Complications Associated With Preoperative Immunosuppression in Patients Undergoing Total Elbow Arthroplasty

PURPOSE

Patients considering total elbow arthroplasty (TEA) may be receiving immunosuppressive therapy; however, the relationship between immunosuppressive medications and postoperative complications is not well defined. Our purpose was to assess the relationship between preoperative immunosuppression and short-term complications following TEA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2005 to 2020 to identify patients undergoing TEA. Procedures indicated for malignancy or infection were excluded. Patients were grouped according to preoperative chronic immunosuppressive status. Demographic and operative characteristics were compared between groups. The 30-day incidence of complications and reoperations were compared between groups. Multiple logistic regression models, inverse-weighted by propensity scores, were used to calculate odds ratio (OR) of experiencing any complication or return to the operating room based on immunosuppression status and other demographic characteristics.

RESULTS

A total of 769 patients undergoing TEA were included, of whom 142 (18.5%) received chronic immunosuppression. Distribution of age, sex, race, body mass index, diabetes, and American Society of Anesthesiologists classification differed significantly between groups. Most procedures were performed on an inpatient basis, and the median operative duration was 148 minutes. Most procedures were indicated for fracture in the nonimmunosuppressed group and rheumatoid arthritis in the immunosuppressed group. Overall complication rates were 7.0% for immunosuppressed patients and 10.2% for nonimmunosuppressed patients. The incidence of complications and reoperations did not significantly differ between groups. After controlling for confounding and adjusting for patient characteristics, immunosuppressed patients were 0.52 times less likely to experience a complication. Additionally, there was no association between immunosuppression status and odds of return to the operating room.

CONCLUSION

Similar rates of complications were observed following TEA, regardless of preoperative immunosuppression status. Chronic immunosuppression does not appear to increase the rates of postoperative complications for patients undergoing TEA.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Total elbow arthroplasty cases involving orthopaedic residents do not affect short-term postoperative complications

Background

Impact of resident participation on short-term postoperative outcomes after total elbow arthroplasty has not been studied. The aim was to investigate whether resident participation affects postoperative complication rates, operative time, and length of stay.

Methods

The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2006 to 2012 for patients undergoing total elbow arthroplasty. A 1:1 propensity score match was performed to match resident cases to attending-only cases. Comorbidities, surgical time, and short-term (30-day) postoperative complications were compared between groups. Multivariate Poisson regression was used to compare the rates of postoperative adverse events between groups.

Results

After propensity score match, 124 cases (50% with resident participation) were included. Adverse event rate after surgery was 18.5%. On multivariate analysis, there were no significant differences between attending-only cases and resident involved cases, with regards to short-term major complications, minor complications, or any complications (all p > 0.071). Total operative time was similar between cohorts (149.16 vs. 165.66 min; p = 0.157). No difference was observed in the length of hospital stay (2.95 vs. 2.6 days), p = 0.399.

Discussion

Resident participation during total elbow arthroplasty is not associated with increased risk for short-term medical or surgical postoperative complications or operative efficiency.

Shared and unique risk factors for readmission exist following upper and lower extremity arthroplasty in the 30-day postoperative period

PURPOSE

Joint arthroplasty has become increasingly more common in the United States, and it is important to examine the patient-based risk factors and surgical variables associated with hospital readmissions. The purpose of this study was to identify stratified rates and risk factors for readmission after upper extremity (shoulder, elbow, and wrist) and lower extremity (hip, knee, and ankle) arthroplasty.

METHODS

All patients undergoing upper and lower extremity arthroplasty from 2008-2018 were identified using the National Surgical Quality Improvement Program dataset. Patient demographics, medical comorbidities and surgical characteristics were examined utilizing uni- and multi-variate analysis for significant predictors of 30-days hospital readmission.

RESULTS

A total of 523,523 lower and 25,215 upper extremity arthroplasty patients were included in this study. A number of 22,183 (4.2%) lower and 1072 (4.4%) upper extremity arthroplasty patients were readmitted within 30 days of discharge. Significant risk factors for 30-days readmission after lower extremity arthroplasty included age, Body Mass Index (BMI), operative time, dependent functional status, American Society of Anesthesiologists (ASA) score ≥3, increased length of stay, and various medical comorbidities such as diabetes, tobacco dependency, and chronic obstructive pulmonary disease (COPD). An overweight BMI was associated with a lower odds of 30-days readmission when compared to a normal BMI for lower extremity arthroplasty. Analysis for upper extremity arthroplasty revealed similar findings of significant risk factors for 30-days hospital readmission, although diabetes mellitus was not found to be a significant risk factor.

CONCLUSION

Nearly one in 25 patients undergoing upper and lower extremity arthroplasty experiences hospital readmission within 30-days of index surgery. There are several modifiable risk factors for 30-days hospital readmission shared by both lower and upper extremity arthroplasty, including tobacco smoking, COPD, and hypertension. Optimization of these medical comorbidities may mitigate the risk short-term readmission following joint arthroplasty procedures and improve overall cost effectiveness of perioperative surgical care.

Comparison of 90-day complication rates and readmissions of primary total elbow arthroplasty in elective and traumatic cases: a single center experience

INTRODUCTION

The purpose of this study is to compare the 90 day complication rates of primary Total Elbow Arthroplasty (TEA) performed for arthritis (primary-OA; rheumatoid arthritis-RA) versus those performed for distal humerus fractures (DHF).

METHODS

Patients who underwent a TEA from 2015 to 2021 were identified from our institutional database and placed into cohorts based on surgical indications (TEA-OA, TEA-RA and TEA-DHF). Chart review was conducted to analyze the prevalence of complications, emergency department (ED) visits, readmissions, and secondary procedures in the first 90 day post-operative period. Complications included but were not limited to wound complications, hematoma, infection (superficial or deep), nerve palsy, periprosthetic fracture/failure and others.

RESULTS

49 patients who underwent TEA were included in this study: (DHF = 19, OA = 14, RA = 16). Six complications occurred within the first 90 days of surgery. There were two periprosthetic joint infections (PJI) in the OA group, requiring irrigation and debridement (I & D) within the first 90 days of surgery. There were three post-operative ulnar nerve palsies and one PJI requiring I & D in the TEA-RA group. Compared to the TEA-DHF and TEA-OA groups, the RA group had higher rates of all-cause complications (p = 0.03) and nerve palsy (p = 0.03). There were no significant differences between groups in readmissions (p = 0.27) or secondary interventions (p = 0.27).

CONCLUSION

The 90-day complication/readmission rates of TEA preformed for DHFs is lower than those preformed for OA and RA. These differences could be related to the underlying chronic inflammatory etiology and side effect of treatments (intraarticular steroid injection, and biologics) received by patients with arthritis.

LEVEL OF EVIDENCE

Retrospective Cohort Study, level IV.

Influence of medical comorbidity and surgical indication on total elbow arthroplasty cost of care

BACKGROUND

Movement toward providing value-based musculoskeletal care requires understanding the cost associated with surgical care as well as the drivers of these costs. The aim of this study was to investigate the effect of common medical comorbidities and specific total elbow arthroplasty (TEA) indications on reimbursement costs throughout the 90-day TEA episode of care. The secondary aim was to identify the drivers of these costs.

METHODS

Administrative health claims for patients who underwent orthopedic intervention between 2010 and 2020 were queried using specific disease classification and procedural terminology codes from a commercially available national database of 53 million patients. Patients with commercial insurance were divided into various cohorts determined by different surgical indications and medical comorbidities. The reimbursement costs of the surgical encounter, 89-day postoperative period, and total 90-day period in each cohort were evaluated. The cost drivers for the 89-day postoperative period were also determined. Analyses were performed using descriptive statistics and the Kruskal-Wallis test for comparison.

RESULTS

A total of 378 patients who underwent TEA were identified. The mean reimbursement cost of the surgical encounter ($13,393 ± $8314) did not differ significantly based on patient factors. The mean reimbursement cost of the 89-day postoperative period ($4232 ± $2343) differed significantly when stratified by surgical indication (P < .0001) or by medical comorbidity (P < .0001). The indication of rheumatoid arthritis ($4864 ± $1136) and the comorbidity of chronic kidney disease ($5873 ± $1165) had the most expensive postoperative period. In addition, the total 90-day reimbursement cost ($16,982 ± $4132) differed significantly when stratified by surgical indication (P = .00083) or by medical comorbidity (P < .0001), with the indication of acute fracture ($18,870 ± $3971) and the comorbidity of chronic pulmonary disease ($19,194 ± $3829) showing the highest total 90-day cost. Inpatient costs related to readmissions represented 38% of the total reimbursement cost. The overall readmission rate was 5.0%, and the mean readmission cost was $16,296.

CONCLUSION

TEA reimbursements are significantly influenced by surgical indications and medical comorbidities during the postoperative period and the total 90-day episode of care. As the United States transitions to delivering value-based health care, the need for surgeons and policy makers to understand treatment costs associated with different patient-level factors will expand.

Machine learning prediction of postoperative unplanned 30-day hospital readmission in older adult

Background: Although unplanned hospital readmission is an important indicator for monitoring the perioperative quality of hospital care, few published studies of hospital readmission have focused on surgical patient populations, especially in the elderly. We aimed to investigate if machine learning approaches can be used to predict postoperative unplanned 30-day hospital readmission in old surgical patients.

Methods: We extracted demographic, comorbidity, laboratory, surgical, and medication data of elderly patients older than 65 who underwent surgeries under general anesthesia in West China Hospital, Sichuan University from July 2019 to February 2021. Different machine learning approaches were performed to evaluate whether unplanned 30-day hospital readmission can be predicted. Model performance was assessed using the following metrics: AUC, accuracy, precision, recall, and F1 score. Calibration of predictions was performed using Brier Score. A feature ablation analysis was performed, and the change in AUC with the removal of each feature was then assessed to determine feature importance.

Results: A total of 10,535 unique surgeries and 10,358 unique surgical elderly patients were included. The overall 30-day unplanned readmission rate was 3.36%. The AUCs of the six machine learning algorithms predicting postoperative 30-day unplanned readmission ranged from 0.6865 to 0.8654. The RF + XGBoost algorithm overall performed the best with an AUC of 0.8654 (95% CI, 0.8484–0.8824), accuracy of 0.9868 (95% CI, 0.9834–0.9902), precision of 0.3960 (95% CI, 0.3854–0.4066), recall of 0.3184 (95% CI, 0.259–0.3778), and F1 score of 0.4909 (95% CI, 0.3907–0.5911). The Brier scores of the six machine learning algorithms predicting postoperative 30-day unplanned readmission ranged from 0.3721 to 0.0464, with RF + XGBoost showing the best calibration capability. The most five important features of RF + XGBoost were operation duration, white blood cell count, BMI, total bilirubin concentration, and blood glucose concentration.

Conclusion: Machine learning algorithms can accurately predict postoperative unplanned 30-day readmission in elderly surgical patients.

Association of Diabetes Mellitus With Postoperative Complications and Mortality After Non-Cardiac Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Although a variety of data showing that diabetes mellitus (DM) (Type 1 or Type 2) is associated with postoperative complication, there is still a lack of detailed studies that go through the specific diabetic subgroups. The goal of this meta-analysis is to assess the relationship between DM and various complications after non-cardiac surgery.

METHODS

We searched articles published in three mainstream electronic databases (PubMed, EMBASE, Web of science) before November, 2020. A random effects model was conducted since heterogeneity always exist when comparing results between different types of surgery.

RESULTS

This paper included 125 studies with a total sample size of 3,208,776 participants. DM was a risk factor for any postoperative complication (Odds ratio (OR)=1.653 [1.487, 1.839]). The risk of insulin-dependent DM (OR=1.895 [1.331, 2.698]) was higher than that of non-insulin-dependent DM (OR=1.554 [1.061, 2.277]) for any postoperative complication. DM had a higher risk of infections (OR=1.537 [1.322, 1.787]), wound healing disorders (OR=2.010 [1.326, 3.046]), hematoma (OR=1.369 [1.120, 1.673]), renal insufficiency (OR=1.987 [1.311, 3.013]), myocardial infarction (OR=1.372 [0.574, 3.278]). Meanwhile, DM was a risk factor for postoperative reoperation (OR=1.568 [1.124, 2.188]), readmission (OR=1.404 [1.274, 1.548]) and death (OR=1.606 [1.178, 2.191]).

CONCLUSIONS

DM is a risk factor for any postoperative complications, hospitalization and death after non-cardiac surgery. These findings underscore the importance of preoperative risk factor assessment of DM for the safe outcome of surgical patients.