The Incremental Cost of Inpatient Venous Thromboembolism After Hip Fracture Surgery

The association between admission mean corpuscular volume and preoperative deep venous thrombosis in geriatrics hip fracture: a retrospective study

OBJECTIVE

This study evaluated the association between admission MCV and preoperative deep vein thrombosis (DVT) in geriatric hip fractures.

METHODS

Older adult patients with hip fractures were screened between January 2015 and September 2019. The demographic and clinical characteristics of the patients were collected at the largest trauma center in northwest China. MCV was measured at admission and converted into a categorical variable according to the quartile. Multivariate binary logistic regression and generalized additive model were used to identify the linear and nonlinear association between MCV and preoperative DVT. Analyses were performed using EmpowerStats and the R software.

RESULTS

A total of 1840 patients who met the criteria were finally enrolled and divided into four groups according to their MCV levels. The mean MCV was 93.82 ± 6.49 (80.96 to 105.91 fL), and 587 patients (31.9%) were diagnosed with preoperative DVT. When MCV was a continuous variable, the incidence of preoperative DVT increased with mean corpuscular volume. In the fully adjusted model, admission MCV was positively correlated with the incidence of preoperative DVT (OR: 1.03; 95% CI: 1.01-1.05; P = 0.0013). After excluding the effect of other factors, each additional 1fL of MCV increased the prevalence of preoperative DVT by 1.03 times as a continuous variable.

CONCLUSION

MCV was linearly associated with preoperative DVT in geriatric patients with hip fractures and could be considered a predictor of DVT risk. The MCV may contribute to risk assessment and preventing adverse outcomes in the elderly.

STUDY REGISTRATION

This study is registered on the website of the Chinese Clinical Trial Registry (ChiCTR: ChiCTR2200057323).

Use of Conditionally Essential Amino Acids and the Economic Burden of Postoperative Complications After Fracture Fixation: Results from a Cost Utility Analysis

Objective

To measure the economic impact of conditionally essential amino acids (CEAA) among patients with operative treatment for fractures.

Methods

A decision tree model was created to estimate changes in annual health care costs and quality of life impact due to complications after patients underwent operative treatment to address a traumatic fracture. The intervention of interest was the use of CEAA alongside standard of care as compared to standard of care alone. Patients were required to be aged ≥18 and receive the surgery in a US Level 1 trauma center. The primary outcomes were rates of post-surgical complications, changes in patient quality adjusted life years (QALYs), and changes in cost. Cost savings were modeled as the incremental costs (in 2022 USD) of treating complications due to changes in complication rates.

Results

The per-patient cost of complications under CEAA use was $12,215 compared to $17,118 under standard of care without CEAA. The net incremental cost savings per patient with CEAA use was $4902, accounting for a two-week supply cost of CEAA. The differences in quality-adjusted life years (QALYs) under CEAA use and no CEAA use was 0.013 per person (0.739 vs 0.726). Modeled to the US population of patients requiring fracture fixations in trauma centers, the total value of CEAA use compared to no CEAA use was $316 million with an increase of 813 QALYs per year. With a gain of 0.013 QALYs per person, valued at $150,000, and the incremental cost savings of $4902 resulted in net monetary benefit of $6852 per patient. The incremental cost-effectiveness ratio showed that the use of CEAA dominated standard of care.

Conclusion

CEAA use after fracture fixation surgery is cost saving. Level of Evidence: Level 1 Economic Study.

Is There a Role for Anti-factor Xa Activity Assay in Venous Thromboembolism Prophylaxis Management Among Orthopaedic Trauma Patients? Systematic Review and Meta-analysis

OBJECTIVES

To determine the effect of anti-factor Xa assay dosing of low-molecular-weight heparin (LMWH) on rates of venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, and mortality among orthopaedic trauma patients.

DATA SOURCES

PubMed/MEDLINE, Embase, Ovid, Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov , and Scopus were systematically searched from inception of the database to 2021.

STUDY SELECTION

Prospective, retrospective, and randomized controlled trial studies were included if they compared rates of VTE, DVT, PE, bleeding, and/or mortality between orthopaedic trauma patients receiving anti-factor Xa-based LMWH dosing and those receiving standard dosing.

DATA EXTRACTION

Two independent reviewers screened titles and abstracts for eligibility. Study characteristics including study design, inclusion criteria, and intervention were extracted.

DATA SYNTHESIS

Meta-analysis was performed using pooled proportion of events (effect size) with 95% confidence intervals. A random-effects model was used. Heterogeneity was quantified by Higgins I 2 . Heterogeneity and variability between subgroups indicated differences in the pooled estimate represented by a P -value.

RESULTS

Six hundred eighty-five studies were identified, and 10 studies including 2870 patients were included. In total, 30.3% and 69.7% received an adjusted and nonadjusted dose of LMWH, respectively. The rate of VTE and DVT were significantly lower in the anti-factor Xa-adjusted cohort, whereas there was no statistically significant difference in rates of PE, bleeding, or mortality between the cohorts.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that anti-factor Xa activity assay dosing of LMWH among orthopaedic trauma patients leads to a reduction in overall DVT rates, although not PE rates, without an increased risk of bleeding events.

LEVEL OF EVIDENCE

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

Risk factors for deep vein thrombosis in patients with pelvic or lower-extremity fractures in the emergency intensive care unit

Introduction

This study aimed to investigate the incidence of deep vein thrombosis (DVT) in patients with pelvic or lower-extremity fractures in the emergency intensive care unit (EICU), explore the independent risk factors for DVT, and investigate the predictive value of the Autar scale for DVT in these patients.

Methods

The clinical data of patients with single fractures of the pelvis, femur, or tibia in the EICU from August 2016 to August 2019 were retrospectively examined. The incidence of DVT was statistically analyzed. Logistic regression was used to analyze the independent risk factors for DVT in these patients. The receiver-operating characteristic (ROC) curve was used to evaluate the predictive value of the Autar scale for the risk of DVT.

Results

A total of 817 patients were enrolled in this study; of these, 142 (17.38%) had DVT. Significant differences were found in the incidence of DVT among the pelvic fractures, femoral fractures, and tibial fractures (P < 0.001). The multivariate logistic regression analysis showed multiple injuries (OR = 2.210, 95% CI: 1.166-4.187, P = 0.015), fracture site (compared with tibia fracture group, femur fracture group OR = 4.839, 95% CI: 2.688-8.711, P < 0.001; pelvic fracture group OR = 2.210, 95% CI: 1.225-3.988, P = 0.008), and Autar score (OR = 1.198, 95% CI: 1.016-1.353, P = 0.004) were independent risk factors for DVT in patients with pelvic or lower-extremity fractures in the EICU. The area under the ROC curve (AUROC) of the Autar score for predicting DVT was 0.606. When the Autar score was set as the cutoff value of 15.5, the sensitivity and specificity for predicting DVT in patients with pelvic or lower-extremity fractures were 45.1% and 70.7%, respectively.

Discussion

Fracture is a high-risk factor for DVT. Patients with a femoral fracture or multiple injuries have a higher risk of DVT. In the case of no contraindications, DVT prevention measures should be taken for patients with pelvic or lower-extremity fractures. Autar scale has a certain predictive value for the occurrence of DVT in patients with pelvic or lower-extremity fractures, but it is not ideal.

Increased Morbidity With Diagnosis and Treatment of Pulmonary Embolism After Total Joint Arthroplasty: A Matched Control Analysis of 30,000 Patients

BACKGROUND

Currently, the risks associated with the diagnosis of pulmonary embolism (PE) and subsequent treatment are not well known. The purpose of our study is to quantify the specific in-hospital complications and resource utilization of patients with PE following total joint arthroplasty when compared to a matched cohort.

METHODS

The Nationwide Inpatient Sample database was used to identify patients undergoing primary hip and knee arthroplasty from January 1993 to December 2008. PE was determined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. In-hospital complications, costs, and length of stay for patients with PE were compared to patients without PE, matched on the basis of age, gender, procedure (total hip arthroplasty vs total knee arthroplasty), year of surgery, morbid obesity, and all 28 comorbid-defined elements of the Elixhauser Comorbidity Index.

RESULTS

Of 8,634,038 procedures, 30,281 (0.4%) patients had a PE after total joint arthroplasty. In total, 29,917 (98%) were matched one-to-one with patients without PE. Patients with PE had a substantially higher risk of all postoperative in-hospital complications: deep vein thrombosis (odds ratio [OR] 17), peripheral vascular (OR 34), hematoma (OR 3.7), and gastrointestinal bleeding (OR 7.0) (all P < .001). Mortality was significantly higher in patients with PE compared to patients without PE (3.4% vs 0.1%, OR 30), along with total hospital costs, lengths of stay, and rates of discharge to rehabilitation facilities.

CONCLUSION

After controlling for comorbidities patients with PE have a significantly higher risk for complications including in-hospital mortality and higher hospital costs when compared to patient without PE.

Low Mean Platelet Volume is Associated with Deep Vein Thrombosis in Older Patients with Hip Fracture

This study aimed to explore the association between mean platelet volume (MPV) and preoperative deep vein thrombosis (DVT) in older patients with hip fracture. A total of 352 consecutive older patients with hip fracture were included from January 2014 to December 2020. MPV values were measured on admission, and color Doppler ultrasonography was performed for DVT screening before the planned surgery. The receiver operating characteristic (ROC) curve was used to establish the optimal cut-off value for the prediction of DVT. Univariate and multivariate logistic regression analysis were used to examine the association between factors and DVT. The overall prevalence of preoperative DVT was 15.1%, and patients with DVT had a lower value of MPV than non-DVT patients (11.6 ± 1.2 fL vs 12.3 ± 1.4 fL, P < .01). The cut-off point according to the ROC curve for MPV was 13.3 fL, and multivariate logistic regression analysis showed that MPV level < 13.3 fL was significantly associated with an increased risk of DVT (OR = 4.857, 95% CI: 1.091-21.617, P = .038), and with every 1.0 fL decrease in MPV, the risk increased by 27.7% (OR = 1.277, 95% CI: 1.001-1.629, P = .047). Our findings indicate that a low MPV level is associated with DVT in older patients with hip fracture. As MPV is a simple indicator that can be calculated from the blood routine test, it may be a potential biomarker of DVT with the combination of other tests, further studies are needed to confirm these results.

Incremental cost of venous thromboembolism in trauma patients with contraindications to prophylactic anticoagulation: a prospective economic study

Venous thromboembolism (VTE) is common in patients after major trauma. Attributable cost of VTE and whether this is related to the severity of injury have not been thoroughly investigated. We aimed to define the hospitalization costs of VTE and assess whether the costs were related to the severity of injury in this prospective economic study. Cost data of each patient enrolled in the da Vinci trial were drawn from hospital finance departments and standardized to 2020 Australian dollars (A$); and Injury Severity Score and Trauma Embolic Scoring System were used to quantify the severity of injury. Of the 223 patients who had complete financial cost data available until day-90 follow-up, 37 (16.6%) developed VTE, including upper limb (n = 3) and lower limb deep vein thrombosis (n = 25), pulmonary embolism (n = 7) and clots entrapped in a vena cava filter. The median total radiology (A$4307) as well as the hospitalization costs (A$138,526) of those who had VTE were significantly higher than those without VTE (A$1210; p < 0.001 and A$105,842; p = 0.023, respectively). The incremental hospitalization cost attributable to VTE was most apparent among those who had sustained extremely severe injuries, and estimated to be between A$43,292 (95% confidence interval [CI] 12,624-73,961, p = 0.006) and 41,680 (95%CI 7766-75,594, p = 0.016) after adjusted for Trauma Embolic Scoring System and Injury Severity Scores, respectively. VTE was common after major trauma and incurred a substantial incremental financial cost to the healthcare system, especially among those who had extremely severe injuries.

Postoperative venous thromboembolism event increases risk of readmissions and reoperation following total joint arthroplasty: a propensity-matched cohort study

PURPOSE

The clinical impact of postoperative venous thromboembolism (VTE) following total joint arthroplasty (TJA) remains unclear. In this study, we evaluate the effect of VTE following TJA on postoperative outcomes including discharge disposition, readmission rates, and revision rates.

METHODS

We retrospectively reviewed all patients over the age of 18 who underwent primary, elective THA or TKA between 2013 and 2020. Patients were stratified into two cohorts based on whether or not they had a VTE following their procedure. Baseline patient demographics and clinical outcomes such as readmissions and revisions were collected. Propensity score matching was performed to limit significant demographic differences, while independent sample t-tests and Pearson's chi-squared test were used to compare outcomes of interest between the groups.

RESULTS

After propensity score matching, there were 109 patients in each cohort, representing a total of 218 patients for the matched comparison. Prior to matching, the VTE cohort was noted to have a significantly higher BMI than the non-VTE cohort (32.22 ± 6.27 vs 30.93 ± 32.04 kg/m², p = 0.032). All other patient demographics were similar. Compared to the non-VTE cohort, the VTE cohort was less likely to be discharged home (66.1% vs 80.7%; p = 0.021), had a higher rate of 90-day all-cause readmissions (27.5% vs 9.2%, p = 0.001), and a higher two-year revision rate (11.0% vs 0.9%, p = 0.003).

CONCLUSION

Patients with postoperative VTE were less likely to be discharged home and had higher 90-day readmission and two-year revision rates. Therefore, mitigating perioperative risk factors, initiating appropriate long-term anticoagulation, and maintaining close follow-up for patients with postoperative VTE may play significant roles in decreasing hospital costs and the economic burden to the healthcare system.

LEVEL OF EVIDENCE III

Retrospective Cohort Study.

Study on the Risk Factors of Preoperative Deep Vein Thrombosis (DVT) in Patients With Lower Extremity Fracture

Objective:

The objective of this work is to discuss and analyze the related factors of lower extremity fracture complicated by preoperative deep vein thrombosis (DVT).

Methods:

A total of 11,891 patients with closed fractures of lower extremities were selected. By analyzing each patient’s gender, age, presence or absence of diabetes and hypertension, preoperative plasma D-dimer level, and color Doppler ultrasound of the lower extremity vein, the pertinent factors of the patients with lower extremity fractures complicated by preoperative DVT were analyzed.

Results:

A total of 578 with preoperative DVT were detected, displaying a total incidence of 4.86%. All patients were categorized into either the DVT group or non-DVT group. The results demonstrate that there were statistically significant differences between the 2 groups in age, the presence of diabetes and hypertension, the fracture site, and the preoperative plasma D-dimer level (P < 0.05). Logistic multivariate analysis revealed that age, the presence of diabetes, and the preoperative plasma D-dimer level of patients were independent risk factors for lower extremity fracture complicated by DVT.

Conclusion:

Age, the presence of diabetes, the fracture site, and increased D-dimer levels were found to be potential risk factors and indicators for preoperative DVT in patients with lower extremity fractures. In addition, the preoperative plasma D-dimer level has certain guiding significance for the prediction of venous thrombosis after lower extremity fracture, which is conducive to the early prediction and diagnosis of DVT, but it often must be followed with good clinic acumen and examinations.

Thromboprophylaxis across orthopaedic surgery: Bibliometric analysis of the most cited articles

PURPOSE

One of the most common adverse events after orthopaedic surgery, with a potential for subsequent serious morbidity and mortality is venous thromboembolism (VTE). Bibliometric analysis has been performed regarding many topics and across orthopaedics. As DVT prophylaxis is a major component of both orthopaedic surgery considerations and research, a bibliometric analysis in this area would prove beneficial in not only in understanding the research done in the field thus far, but would also direct future research efforts.

METHODS

The Web of Science (WoS) database from the Institute of Scientific Information (ISI) was used to compile articles for bibliometric analysis using Boolean search: ((Orthopaedic∗ OR Orthopaedic∗) AND (thromboprophylaxis OR Thromboembolism OR Deep vein thrombosis OR thrombus OR embolism OR anticoagulation OR Embolus OR prophylaxis)).

RESULTS

The Top 100 cited articles included in the final list generated a total of 21,099 citations. The highest cited article was Prevention of venous thromboembolism by Geerts et al. published in Chest, which had a total of 2802 on WoS, and a calculated citation density of 215.54 of citations/years since publication. Comparing the overall citation against the year of publication there was a slight positive trend favoring more recent publications (R-value: 0.142; adjusted R-squared: 0.01; p = 0.16). Analysis of an articles Level of Evidence (LOE), 17 were grade with a level of I.

CONCLUSIONS

Orthopaedic thromboprophylaxis is an ever-changing field that is at the forefront of orthopaedic literature. The significant trend favoring high quality research within orthopaedic thromboprophylaxis demonstrates the importance of this topic and there was a need for a guide to best understand the evolution of DVT prophylaxis.