Trends in Comorbidities and Complications Using ICD-9 and ICD-10 in Total Hip and Knee Arthroplasties

Outcomes of Hip Decompression with Segmental Elevation of Necrosis in Advanced Osteonecrosis of the Femoral Head

BACKGROUND

Hip decompression(HD) has shown promising outcomes for osteonecrosis of the femoral head(ONFH),particularly in early stages of the disease. Prompt intervention may delay progression to total hip arthroplasty(THA). This study evaluated the outcomes of HD with elevation of the collapsed segment in patients who have advanced stages of the disease, specifically those who had segmental collapse of the femoral head.

METHODS

There were 11 patients (12 hips)who underwent HD with elevation of a collapsed femoral head segment between 2007 and 2020 who were included. There were five hips classified as Association Research Circulation Osseous(ARCO) IIIA and seven as IIIB. According to the Japanese Investigation Committee(JIC) classification, six hips were type C1 and six were type C2. There were four patients who underwent HD via surgical hip dislocation to visually confirm segmental elevation, while the remaining patients underwent percutaneous decompression, where necrotic segment elevation was achieved under pressure with delivery of bone marrow concentrate and demineralized bone matrix. Patient demographics, risk factors, radiologic imaging, operative details, pain scales, and activity-level assessments were collected and analyzed.

RESULTS

Of the 12 hips(58.3%),seven remained free from THA or reoperation at an average follow-up of 7.6 years(range,4.1-10.9). Daily pain at the latest follow-up decreased to a mean of 4 of 10(range,1-5),compared with preoperative values of 7.8 of 10 (range,6-9). Among these hips, patients maintained high functional activity, with scores of 7 or above in the University of California Los Angeles Activity Scale. There were five hips(41.7%) converted to THA at an average of 3.8 years(range, 11 months to 9.5 years),four of which were in type C2 hips.

CONCLUSIONS

Hip decompression with segmental elevation, particularly in C1 hips, may delay THA and improve function in cases that otherwise would have required THA at presentation. This procedure offers a less invasive hip preservation option for later-stage ONFH without affecting future THA.

Predictive value of the hospital frailty risk score in perioperative complications of artificial hip and knee arthroplasty in elderly patients

BackgroundAlthough artificial hip and knee arthroplasty has been widely used, the incidence of perioperative complications remains relatively high due to factors such as long operation time and large surgical incisions. However, the Hospital Frailty Risk Score (HFRS) clinical value for patients undergoing artificial hip and knee arthroplasty in China is not yet clear. This study aims to explore its clinical value in this population.ObjectiveTo explore predictive value of the HFRS in perioperative complications of artificial hip and knee arthroplasty in elderly patients.MethodsElderly patients who underwent artificial hip and knee arthroplasty in our hospital from March 2020 to March 2022 were selected as the study subjects. The patients were divided into the non-frail risk group (HFRS <5 points) and the frail risk group (HFRS ≥5 points) on the basis of the literature grading method. 5-factor modified frailty index (mFI-5) and Charlson Comorbidity Index (CCI) scores were assessed. General data including age, sex, ASA classification, preoperative course, and surgical time were collected through the electronic medical record system. The occurrence of postoperative deep venous thrombosis, periprosthetic infection, hematoma, anemia, and overall complications was recorded. Hospitalization days, surgical costs, and total treatment costs were also calculated for all patients.ResultsThere were no significant differences in age, sex, ASA classification, preoperative course, or surgical time between the two groups (p > 0.05). The frail risk group had significantly higher mFI-5 and CCI scores (p < 0.05). This group also had a higher incidence of deep venous thrombosis and overall complications (p < 0.05), but similar rates of periprosthetic infection, hematoma, and anemia (p > 0.05). ROC analysis showed HFRS had the highest predictive value for postoperative complications (AUC = 0.851) compared to mFI-5 (0.786) and CCI (0.739). Surgical costs were similar (p > 0.05), but the frail group had longer hospital stays and higher total treatment costs (p < 0.05).ConclusionHFRS has better predictive value for perioperative complications in elderly patients undergoing artificial hip and knee arthroplasty compared to mFI-5 and CCI scores, and it can be used for predicting perioperative complications in elderly patients with this surgery.

Trends in the Utilization of Multiorgan Support Among Adults Undergoing High-risk Cardiac Surgery in the United States

OBJECTIVES

To examine trends in the prevalence of multiorgan dysfunction (MODS), utilization of multi-organ support (MOS), and mortality among patients undergoing cardiac surgery with MODS who received MOS in the United States.

DESIGN

Retrospective cohort study.

SETTING

183 hospitals in the Premier Healthcare Database.

PARTICIPANTS

Adults ≥18 years old undergoing high-risk elective or non-elective cardiac surgery.

INTERVENTIONS

none.

MEASUREMENTS AND MAIN RESULTS

The exposure was time (consecutive calendar quarters) January 2008 and June 2018. We analyzed hospital data using day-stamped hospital billing codes and diagnosis and procedure codes to assess MODS prevalence, MOS utilization, and mortality. Among 129,102 elective and 136,190 non-elective high-risk cardiac surgical cases across 183 hospitals, 10,001 (7.7%) and 21,556 (15.8%) of patients developed MODS, respectively. Among patients who experienced MODS, 2,181 (22%) of elective and 5,425 (25%) of non-elective cardiac surgical cases utilized MOS. From 2008-2018, MODS increased in both high-risk elective and non-elective cardiac surgical cases. Similarly, MOS increased in both high-risk elective and non-elective cardiac surgical cases. As a component of MOS, mechanical circulatory support (MCS) increased over time. Over the study period, risk-adjusted mortality, in patients who developed MODS receiving MOS, increased in high-risk non-elective cardiac surgery and decreased in high-risk elective cardiac surgery, despite increasing MODS prevalence and MOS utilization (p<0.001).

CONCLUSIONS

Among patients undergoing high-risk cardiac surgery in the United States, MODS prevalence and MOS utilization (including MCS) increased over time. Risk-adjusted mortality trends differed in elective and non-elective cardiac surgery. Further research is necessary to optimize outcomes among patients undergoing high-risk cardiac surgery.

Incidence and risk factors of blood transfusion after total knee arthroplasty: A retrospective nationwide inpatient sample database study

Introduction

Common postoperative complications of total knee arthroplasty (TKA) include blood transfusion. Although risk factors and incidence of blood transfusion have been studied through national databases, the relative impact of each risk factor needs to be synthesized over a longer time period into a new model need to be revised.

Material and methods

Patient data were extracted from the National Inpatient Sample (NIS), which is the largest hospital care database in the US, and analyse patient data retrospectively from 2010 through 2019. The final data included the patients undergoing TKA. The final analysis assessed the demographics of patients, type of insurance, type of hospital, length of stay (LOS), preoperative comorbidities, total charge, inpatient mortality, medical-surgical postoperative complications.

Results

After extracting data from the NIS database, a total of 1,250,533 patients with TKA were included in the analysis, and the rate of transfusion was 6.60 %. TKA patients who receive blood transfusion had longer LOS (from 2-3 days to 3-4 days), more preoperative comorbidities, higher inpatient mortality rate, and increased total charge (P < 0.001). Moreover, postoperative complications associated with inpatients included sepsis, acute myocardial infarction and shock. Elective admission and private insurance were also regarded as protective factors.

Conclusion

Blood transfusion could bring postoperative complications to patients, which were also linked to health costs and risks. It was also a common preoperative comorbidities for older patients who underwent TKA. Through better blood management strategies, we could reduce patient transfusion rates and improve clinical outcomes.Level of Evidence: Diagnostic Level Ⅲ.

Postoperative Complications Associated with Non-Steroidal Anti-Inflammatory Combinations Used Status-Post Total Hip and Knee Arthroplasty

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in multimodal pain control following total joint arthroplasty (TJA). However, few studies have assessed the complications associated with the combinations of NSAIDs in this population despite the known risks associated with this class of medications. The Premier Healthcare Database was queried to identify adults who underwent primary total hip or knee arthroplasty from 2005-2014. The following most common inpatient combinations of NSAIDs were chosen for analysis: aspirin + celecoxib (A + C), toradol + aspirin (T + A), toradol + ibuprofen (T + I), celecoxib + ibuprofen (C + I), ibuprofen + aspirin (I + A), and toradol + celecoxib (T + C). Primary outcomes included acute kidney injury (AKI), gastrointestinal bleed, and stroke. Secondary outcomes included periprosthetic joint infection (PJI), deep vein thrombosis, and pulmonary embolism. Univariate and multivariate regression analyses were used to compare differences and address confounds. Overall, 195,833 patients were identified. After controlling for confounds, increased odds of AKI was associated with A + C (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.09-1.34, p < 0.001) and decreased odds was associated with T + A (aOR 0.76, 95% CI: 0.69-0.83, p < 0.001). Increased odds of stroke was associated with A + C (aOR: 1.80, 95% CI: 1.15-2.84, p = 0.011); T + I (aOR 3.48, 95% CI: 1.25-9.73, p = 0.017); and I + A (aOR 4.29, 95% CI: 1.06-17.9, p = 0.046). Increased odds of PJI was associated with C + I (aOR: 10.3, 95% CI: 1.35-78.3, p = 0.024). In the TJA patient population, NSAID pairings should be regarded as distinct entities. Our results suggest that combinations including A + C, T + I, I + A, and C + I should be used cautiously. With this knowledge, providers should consider tailoring NSAID prescriptions appropriately.

No difference in short-term readmissions following day-case vs. one overnight stay in patients having hip and knee arthroplasty: a nationwide register study of 51,042 procedures from 2010-2020

BACKGROUND AND PURPOSE

Day-case hip and knee arthroplasty has gained in popularity, but there are conflicting results regarding readmissions. We aimed to investigate differences in 30- and 90-day readmission rates between day-case patients and patients with a single overnight stay following primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA).

PATIENTS AND METHODS

We identified day-case (DC) and overnight (ON) THA, TKA, and UKA patients, operated on between 2010 and 2020, from the Danish National Patient Register. Day-case surgery was defined as discharge on the day of surgery. Overnight readmissions within 30 or 90 days of surgery were considered readmissions. We compared readmission rates between DC and ON patients within arthroplasty types using logistic regression adjusted for patient characteristics and year of surgery. We included 29,486 THAs (1,353 DC and 28,133 ON), 15,116 TKAs (617 DC and 14,499 ON), and 6,440 UKAs (1,528 DC and 4,914 ON).

RESULTS

The 30-day readmission rates were: DC-THA 4.4% vs. ON-THA 4.4% (adjusted odds-ratio [aOR] 1.2, 95% confidence interval [CI] 0.91-1.6), DC-TKA 4.7% vs. ON-TKA 4.4% (aOR 1.1, CI 0.69-1.5), and DC-UKA 3.0% vs. ON-UKA 3.0% (aOR 1.1, CI 0.78-1.5). Similarly, no significant differences were present between DC and ON THA, TKA, and UKA regarding 90-day readmissions or time to readmission.

CONCLUSION

We found no differences in readmission rates between day-case THA, TKA, and UKA patients and patients with a single overnight stay.

Heart-Brain 346-7 Score: the development and validation of a simple mortality prediction score for carbon monoxide poisoning utilizing deep learning

INTRODUCTION

Acute mortality from carbon monoxide poisoning is 1-3%. The long-term mortality risk of survivors of carbon monoxide poisoning is doubled compared to age-matched controls. Cardiac involvement also increases mortality risk. We built a clinical risk score to identify carbon monoxide-poisoned patients at risk for acute and long-term mortality.

METHODS

We performed a retrospective analysis. We identified 811 adult carbon monoxide-poisoned patients in the derivation cohort, and 462 adult patients in the validation cohort. We utilized baseline demographics, laboratory values, hospital charge transactions, discharge disposition, and clinical charting information in the electronic medical record in Stepwise Akaike's Information Criteria with Firth logistic regression to determine optimal parameters to create a prediction model.

RESULTS

In the derivation cohort, 5% had inpatient or 1-year mortality. Three variables following the final Firth logistic regression minimized Stepwise Akaike's Information Criteria: altered mental status, age, and cardiac complications. The following predict inpatient or 1-year mortality: age > 67, age > 37 with cardiac complications, age > 47 with altered mental status, or any age with cardiac complications and altered mental status. The sensitivity of the score was 82% (95% confidence interval: 65-92%), the specificity was 80% (95% confidence interval: 77-83%), negative predictive value was 99% (95% confidence interval: 98-100%), positive predictive value 17% (95% confidence interval: 12-23%), and the area under the receiver operating characteristic curve was 0.81 (95% confidence interval: 0.74-0.87). A score above the cut-off point of -2.9 was associated with an odds ratio of 18 (95% confidence interval: 8-40). In the validation cohort (462 patients), 4% had inpatient death or 1-year mortality. The score performed similarly in the validation cohort: sensitivity was 72% (95% confidence interval: 47-90%), specificity was 69% (95% confidence interval: 63-73%), negative predictive value was 98% (95% confidence interval: 96-99%), positive predictive value was 9% (95% confidence interval: 5-15%) and the area under the receiver operating characteristic curve was 0.70 (95% confidence interval: 60%-81%).

CONCLUSIONS

We developed and validated a simple, clinical-based scoring system, the Heart-Brain 346-7 Score to predict inpatient and long-term mortality based on the following: age > 67, age > 37 with cardiac complications, age > 47 with altered mental status, or any age with cardiac complications and altered mental status. With further validation, this score will hopefully aid decision-making to identify carbon monoxide-poisoned patients with higher mortality risk.

Tranexamic Acid and Prothrombotic Complications Following Total Hip and Total Knee Arthroplasty: A Population-Wide Safety Analysis Accounting for Surgeon Selection Bias

BACKGROUND

Tranexamic acid (TXA) utilization during total joint arthroplasty (TJA) has become ubiquitous. However, concerns remain regarding the risk of thrombotic complications. The goal of this study was to examine the risk of prothrombotic complications in patients who received TXA during total knee (TKA) and total hip arthroplasty (THA).

METHODS

The Premier Healthcare Database was queried for patients who underwent elective TJA. TXA utilization trends were described from 2008 to 2020. Two analyses were performed using ICD-10 codes from 2016 to 2020: (1) patients who received TXA compared to patients who did not receive TXA and, (2) to account for surgeon selection bias, patients whose surgeon utilized TXA consistently (≥90% of cases) compared to patients whose surgeons used TXA infrequently (≤30% of cases). Multivariate and instrumental variable analyses (IVA) were performed to assess outcomes while accounting for confounding factors. TXA utilization increased from 0.1% of cases in 2008 to 89.2% in 2020. From 2016 to 2020, 1,120,858 TJAs were identified (62.1% TKA, 27.9% THA), of which 874,627 (78.0%) received TXA.

RESULTS

Patients who received TXA were at lower risk of prothrombotic (adjusted Odds Ratio (aOR) 0.82, P < .001), bleeding (aOR 0.75, P < .001), and infectious complications (aOR 0.91, P < 0.001). Furthermore, patients who underwent surgery from surgeons who utilized TXA consistently were at lower risk for prothrombotic (aOR 0.90, P < .001) and bleeding (aOR 0.72, P < .001) complications.

CONCLUSION

The widespread utilization of TXA during elective TJA was not associated with increased rates of prothrombotic complications. These findings persisted after accounting for surgeon selection bias.

LEVEL OF EVIDENCE

Level III.

The Rise of Medicare Advantage: Effects on Total Joint Arthroplasty Patient Care and Research

BACKGROUND

Medicare Advantage (MA) plans are popular among Medicare-eligible patients, but little is known about MA in lower-extremity total joint arthroplasty (TJA). The purpose of this study was to describe trends in MA utilization and analyze differences in patient characteristics and postoperative outcomes between patients undergoing primary TJA using traditional Medicare (TM) or MA plans.

METHODS

Patients ≥65 years of age who underwent primary total knee or total hip arthroplasty were identified using the Premier Healthcare Database. Patients were categorized into TM and MA cohorts. Data from 2004 to 2020 were used to describe trends in insurance coverage. Data from 2015 to 2020 were used to identify differences in patient characteristics and postoperative complications using ICD-10 codes. Multivariate analyses were performed using 2015 to 2020 data to account for potential confounders.

RESULTS

From 2004 to 2020, the proportion of patients with MA increased from 7.9% to 34.4%, while those with TM decreased from 83.7% to 54.0%. Of the 697,317 patients who underwent primary elective TJA from 2015 to 2020, 471,439 (67.6%) had TM coverage and 225,878 (32.4%) had MA coverage. The cohorts were similar in terms of age and sex. However, a higher proportion of Black patients (8.29% compared with 4.62%; p < 0.001) and a lower proportion of White patients (84.0% compared with 89.2%; p < 0.001) were enrolled in MA compared with TM. After controlling for confounders, patients with MA had higher odds of surgical site infection (adjusted odds ratio [aOR]: 1.15; 95% confidence interval [CI]: 1.04 to 1.47; p = 0.031), periprosthetic joint infection (aOR: 1.10; 95% CI: 1.03 to 1.18; p = 0.006), stroke (aOR: 1.15; 95% CI: 1.02 to 1.31; p = 0.026), and acute kidney injury (aOR: 1.08; 95% CI: 1.04 to 1.11; p < 0.001), but lower odds of urinary tract infection (aOR: 0.94; 95% CI: 0.90 to 0.98; p = 0.003).

CONCLUSIONS

From 2004 to 2020, the number of patients utilizing MA increased markedly such that 1 in 3 were covered by MA in 2020. From 2015 to 2020, patients who were non-White were more likely to have MA than TM, and the MA group had a higher rate of several postoperative complications compared with the TM group. As TM claims data inform health-care policy and clinical decisions, this change portends future challenges, including limitations in arthroplasty registry research, an increase in the administrative burden of surgeons, and a potential worsening of social disparities in health care.

Administrative Data Use in National Registry Efforts: Blessing or Curse?

"Big data" refers to a growing field of large database research. Administrative data, a subset of big data, includes information from insurance claims, electronic medical records, and registries that can be useful for investigating novel research questions. While its use provides salient advantages, potential researchers relying on big data would benefit from knowing about how these databases are coded, common errors they may encounter, and how to best use large data to address various research questions. In the first section of this paper, Dr. Nicholas A. Bedard addresses the four major pitfalls to avoid with diagnosis and procedure codes in administrative data. In the next section, Dr. Jeffrey N. Katz et al. focus on the strengths and limitations of administrative data, suggesting methods to mitigate these limitations. Lastly, Dr. Elena Losina et al. review the uses and misuses of large databases for cost-effectiveness research, detailing methods for careful economic evaluations.

Not all Total Hip and Knee Arthroplasties Are the Same: What Are the Implications in Large Database Studies?

BACKGROUND

The use of claims databases for research after total hip and knee arthroplasty (THA, TKA) has increased exponentially. These studies rely on accurate coding, and inadvertent inclusion of patients with nonroutine indications may influence results. The purpose of this study was to evaluate the complexity of THA and TKA captured by CPT code and determine if complication rates vary based on the indication.

METHODS

The NSQIP database was queried using CPT codes 21730 and 27447 to identify patients undergoing THA and TKA from 2018 to 2019. The surgical indication was classified based on the ICD-10 diagnosis code as routine primary, complex primary, inflammatory, fracture, oncologic, revision, infection, or indeterminant. Patient factors and 30-day complications, readmission, reoperation, and wound complications were compared.

RESULTS

A total of 86,009 THA patients had 703 ICD-10 diagnosis codes and 91.4% were routine primary indications. Complication rates were: routine primary 7.4%, complex primary 11.3%, inflammatory 12.5%, fracture 23.9%, oncologic 32.4%, revision 26.9%, infection 38.7%, and indeterminant 10.3% (P < .0001). 137,500 TKA patients had 552 ICD-10 diagnosis codes and 96.1% were routine primary cases. Complication rates were: routine primary 5.9%, complex primary 8.0%, inflammatory 7.2%, fracture 38.9%, oncologic 32.7%, revision 13.3%, infection 37.7%, and indeterminant 9.6% (P < .0001). Routine primary arthroplasty had significantly lower rates of reoperation, readmission, and wound complications.

CONCLUSION

Using CPT code alone captures 10% of THA and 4% of TKA patients with procedures for nonroutine primary indications. It is essential to recognize identification of patients simply by CPT code has the potential to inadvertently introduce bias, and surgeons should critically assess methods used to define the study populations.

Transitions between versions of the International Classification of Diseases and chronic disease prevalence estimates from administrative health data: a population-based study

Background

Diagnosis codes in administrative health data are routinely used to monitor trends in disease prevalence and incidence. The International Classification of Diseases (ICD), which is used to record these diagnoses, have been updated multiple times to reflect advances in health and medical research. Our objective was to examine the impact of transitions between ICD versions on the prevalence of chronic health conditions estimated from administrative health data.

Methods

Study data (i.e., physician billing claims, hospital records) were from the province of Manitoba, Canada, which has a universal healthcare system. ICDA-8 (with adaptations), ICD-9-CM (clinical modification), and ICD-10-CA (Canadian adaptation; hospital records only) codes are captured in the data. Annual study cohorts included all individuals 18 + years of age for 45 years from 1974 to 2018. Negative binomial regression was used to estimate annual age- and sex-adjusted prevalence and model parameters (i.e., slopes and intercepts) for 16 chronic health conditions. Statistical control charts were used to assess the impact of changes in ICD version on model parameter estimates. Hotelling’s T² statistic was used to combine the parameter estimates and provide an out-of-control signal when its value was above a pre-specified control limit.

Results

The annual cohort sizes ranged from 360,341 to 824,816. Hypertension and skin cancer were among the most and least diagnosed health conditions, respectively; their prevalence per 1,000 population increased from 40.5 to 223.6 and from 0.3 to 2.1, respectively, within the study period. The average annual rate of change in prevalence ranged from -1.6% (95% confidence interval [CI]: -1.8, -1.4) for acute myocardial infarction to 14.6% (95% CI: 13.9, 15.2) for hypertension. The control chart indicated out-of-control observations when transitioning from ICDA-8 to ICD-9-CM for 75% of the investigated chronic health conditions but no out-of-control observations when transitioning from ICD-9-CM to ICD-10-CA.

Conclusions

The prevalence of most of the investigated chronic health conditions changed significantly in the transition from ICDA-8 to ICD-9-CM. These results point to the importance of considering changes in ICD coding as a factor that may influence the interpretation of trend estimates for chronic health conditions derived from administrative health data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13118-8.