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Agarwal AR, Wang KY, Xu AL, Ramamurti P, Zhao A, Best MJ, Srikumaran U. Outpatient Versus Inpatient Total Shoulder Arthroplasty: A Matched Cohort Analysis of Postoperative Complications, Surgical Outcomes, and Reimbursements. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202311000-00010. [PMID: 37973033 PMCID: PMC10656088 DOI: 10.5435/jaaosglobal-d-23-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 07/11/2023] [Accepted: 08/21/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION There has been a trend toward performing arthroplasty in the ambulatory setting. The primary purpose of this study was to compare outpatient and inpatient total shoulder arthroplasties (TSAs) for postoperative medical complications, healthcare utilization outcomes, and surgical outcomes. METHODS Patients who underwent outpatient TSA or inpatient TSA with a minimum 5-year follow-up were identified in the PearlDiver database. These cohorts were propensity-matched based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index > 30). All outcomes were analyzed using chi square and Student t-tests where appropriate. RESULTS Outpatient TSA patients had markedly lower rates of various 90-day medical complications. Outpatient TSA patients had lower risk of aseptic loosening at 2 years postoperation and lower risk of periprosthetic joint infection at 5 years postoperation relative to inpatient TSA patients. Outpatient TSA reimbursements were markedly lower than inpatient TSA reimbursements at the 30-day, 90-day, and 1-year postoperative intervals. CONCLUSION This study found patients undergoing outpatient TSA to be at lowers odds for both postoperative medical and surgical complications compared with those undergoing inpatient TSA. Despite increased risk of postoperative healthcare utilization for readmissions and emergency department visits, outpatient TSA was markedly less expensive at every postoperative time point assessed.
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Affiliation(s)
- Amil R. Agarwal
- From the Johns Hopkins Department of Orthopaedic Surgery, Columbia, MD (Mr. Agarwal, Dr. Xu, Dr. Best, and Dr. Srikumaran); the Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, DC (Mr. Agarwal and Ms. Zhao); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wang); and the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Ramamurti)
| | - Kevin Y. Wang
- From the Johns Hopkins Department of Orthopaedic Surgery, Columbia, MD (Mr. Agarwal, Dr. Xu, Dr. Best, and Dr. Srikumaran); the Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, DC (Mr. Agarwal and Ms. Zhao); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wang); and the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Ramamurti)
| | - Amy L. Xu
- From the Johns Hopkins Department of Orthopaedic Surgery, Columbia, MD (Mr. Agarwal, Dr. Xu, Dr. Best, and Dr. Srikumaran); the Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, DC (Mr. Agarwal and Ms. Zhao); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wang); and the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Ramamurti)
| | - Pradip Ramamurti
- From the Johns Hopkins Department of Orthopaedic Surgery, Columbia, MD (Mr. Agarwal, Dr. Xu, Dr. Best, and Dr. Srikumaran); the Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, DC (Mr. Agarwal and Ms. Zhao); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wang); and the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Ramamurti)
| | - Amy Zhao
- From the Johns Hopkins Department of Orthopaedic Surgery, Columbia, MD (Mr. Agarwal, Dr. Xu, Dr. Best, and Dr. Srikumaran); the Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, DC (Mr. Agarwal and Ms. Zhao); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wang); and the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Ramamurti)
| | - Matthew J. Best
- From the Johns Hopkins Department of Orthopaedic Surgery, Columbia, MD (Mr. Agarwal, Dr. Xu, Dr. Best, and Dr. Srikumaran); the Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, DC (Mr. Agarwal and Ms. Zhao); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wang); and the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Ramamurti)
| | - Uma Srikumaran
- From the Johns Hopkins Department of Orthopaedic Surgery, Columbia, MD (Mr. Agarwal, Dr. Xu, Dr. Best, and Dr. Srikumaran); the Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, DC (Mr. Agarwal and Ms. Zhao); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wang); and the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Ramamurti)
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Gordon AM, Elali FR, Ton A, Schwartz JM, Miller C, Alluri RK. Preoperative Depression Screening in Primary Lumbar Fusion: An Evaluation of Its Modifiability on Outcomes in Patients with Diagnosed Depressive Disorder. World Neurosurg 2023; 176:e173-e180. [PMID: 37178911 DOI: 10.1016/j.wneu.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Studies have reported the detrimental effects of depression following spine surgery; however, none have evaluated whether preoperative depression screening in patients with a history of depression is protective from adverse outcomes and lowers health care costs. We studied whether depression screenings/psychotherapy visits within 3 months before 1- to 2-level lumbar fusion were associated with lower medical complications, emergency department utilization, readmissions, and health care costs. METHODS The PearlDiver database from 2010 to 2020 was queried for depressive disorder (DD) patients undergoing primary 1- to 2-level lumbar fusion. Two cohorts were 1:5 ratio matched and included DD patients with (n = 2,622) and DD patients without (n = 13,058) a preoperative depression screen/psychotherapy visit within 3 months of lumbar fusion. A 90-day surveillance period was used to compare outcomes. Logistic regression models computed odds ratio (OR) of complications and readmissions. P value < 0.003 was significant. RESULTS DD patients without depression screening had significantly greater incidence and odds of experiencing medical complications (40.57% vs. 16.00%; OR 2.71, P < 0.0001). Rates of emergency department utilization were increased in patients without screening versus screening (15.78% vs. 4.23%; OR 4.25, P < 0.0001), despite no difference in readmissions (9.31% vs. 9.53%; OR 0.97, P = 0.721). Finally, 90-day reimbursements ($51,160 vs. $54,731) were significantly lower in the screened cohort (all P < 0.0001). CONCLUSIONS Patients who underwent a preoperative depression screening within 3 months of lumbar fusion had decreased medical complications, emergency department utilization, and health care costs. Spine surgeons may use these data to counsel their patients with depression before surgical intervention.
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Affiliation(s)
- Adam M Gordon
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA; Questrom School of Business, Boston University, Boston, Massachusetts, USA.
| | - Faisal R Elali
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA; College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Andy Ton
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jake M Schwartz
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Chaim Miller
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Ram K Alluri
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Sergesketter AR, Shammas RL, Geng Y, Levinson H, Matros E, Phillips BT. Tracking Complications and Unplanned Healthcare Utilization in Aesthetic Surgery: An Analysis of 214,504 Patients Using the TOPS Database. Plast Reconstr Surg 2023; 151:1169-1178. [PMID: 36728533 PMCID: PMC10790563 DOI: 10.1097/prs.0000000000010148] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tracking surgical complications and unplanned healthcare utilization is essential to inform quality initiatives in aesthetic surgery. This study used the Tracking Operations and Outcomes for Plastic Surgeons database to characterize rates and predictors of surgical complications and unplanned healthcare utilization across common aesthetic surgery procedures. METHODS The Tracking Operations and Outcomes for Plastic Surgeons database was queried for all patients undergoing breast augmentation, liposuction, blepharoplasty, rhinoplasty, and abdominoplasty from 2008 to 2019. Incidence and risk factors for complications and unplanned readmission, reoperation, and emergency room visits were determined. RESULTS A total of 214,504 patients were identified. Overall, 94,618 breast augmentations, 56,756 liposuction procedures, 29,797 blepharoplasties, 24,946 abdominoplasties, and 8387 rhinoplasties were included. A low incidence of perioperative complications was found, including seroma (1.1%), hematoma (0.7%), superficial wound complication (0.9%), deep surgical-site infection (0.2%), need for blood transfusion (0.05%), and deep venous thrombosis/pulmonary embolism (0.1%). Incidence of unplanned readmission, emergency room visits, and reoperation were 0.34%, 0.25%, and 0.80%, respectively. Patients who underwent an abdominoplasty more commonly presented to the emergency room and had unplanned readmissions or reoperations compared with other studied procedures. Furthermore, increased age, diabetes, higher body mass index, American Society of Anesthesiologists class, longer operative times, and pursuit of combined aesthetic procedures were associated with increased risk for unplanned health care use. CONCLUSIONS There is a low incidence of perioperative complications and unplanned healthcare utilization following common aesthetic surgery procedures. Continued entry into large national databases in aesthetic surgery is essential for internal benchmarking and quality improvement. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
| | - Ronnie L. Shammas
- Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, NC
| | | | - Howard Levinson
- Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, NC
| | - Evan Matros
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brett T. Phillips
- Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, NC
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Letchuman V, He L, Mummaneni PV, Agarwal N, Campbell LJ, Shabani S, Chan AK, Abrecht CR, Miller C, Sankaran S, Rambachan A, Croci R, Berven SH, Chou D, Holly LT, Guan Z. Racial Differences in Postoperative Opioid Prescribing Practices in Spine Surgical Patients. Neurosurgery 2023; 92:490-496. [PMID: 36700672 DOI: 10.1227/neu.0000000000002227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 09/11/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND As the opioid epidemic accelerates in the United States, numerous sociodemographic factors have been implicated its development and are, furthermore, a driving factor of the disparities in postoperative pain management. Recent studies have suggested potential associations between the influence of race and ethnicity on pain perception but also the presence of unconscious biases in the treatment of pain in minority patients. OBJECTIVE To characterize the perioperative opioid requirements across racial groups after spine surgery. METHODS A retrospective, observational study of 1944 opioid-naive adult patients undergoing a neurosurgical spine procedure, from June 2012 to December 2019, was performed at a large, quaternary care institute. Postoperative inpatient and outpatient opioid usage was measured by oral morphine equivalents, across various racial groups. RESULTS Case characteristics were similar between racial groups. In the postoperative period, White patients had shorter lengths of stay compared with Black and Asian patients ( P < .05). Asian patients used lower postoperative inpatient opioid doses in comparison with White patients ( P < .001). White patients were discharged with significantly higher doses of opioids compared with Black patients ( P < .01); however, they were less likely to be readmitted within 30 days of discharge ( P < .01). CONCLUSION In a large cohort of opioid-naive postoperative neurosurgical patients, this study demonstrates higher inpatient and outpatient postoperative opioid usage among White patients. Increasing physician awareness to the effect of race on inpatient and outpatient pain management would allow for a modified opioid prescribing practice that ensures limited yet effective opioid dosages void of implicit biases.
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Affiliation(s)
- Vijay Letchuman
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Liangliang He
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Liam J Campbell
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas, USA
| | - Saman Shabani
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher R Abrecht
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
| | - Catherine Miller
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Sujatha Sankaran
- Department of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aksharananda Rambachan
- Department of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rhiannon Croci
- Department of Health Informatics, University of California, San Francisco, San Francisco, California, USA
| | - Sigurd H Berven
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Langston T Holly
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Zhonghui Guan
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
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Billmeyer KN, Ross JK, Hirsch EB, Evans MD, Kline SE, Galdys AL. Predictors of adverse safety events and unscheduled care among an outpatient parenteral antimicrobial therapy (OPAT) patient cohort. Ther Adv Infect Dis 2023; 10:20499361231179668. [PMID: 37332294 PMCID: PMC10272639 DOI: 10.1177/20499361231179668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Background Select circumstances require outpatient parenteral antimicrobial therapy (OPAT). The potency of OPAT agents presents an increased risk of adverse events and unscheduled medical care. We analyzed these outcomes among OPAT recipients as part of the implementation of a collaborative OPAT program. Methods Adult patients discharged home from an academic hospital with OPAT between January 2019 and June 2021 were included in this retrospective cohort; participants discharged between June 2020 and June 2021 were part of the collaborative OPAT program. Patients with cystic fibrosis were excluded. Data on patient characteristics and outcomes were collected from electronic medical records by two reviewers. Multivariable analysis was conducted to identify predictors of vascular access device (VAD) complications, adverse drug events (ADEs), and OPAT-related emergency department (ED) visits and rehospitalizations. Results Among 265 patients included in the cohort, 57 (21.5%) patients experienced a VAD complication; obesity [odds ratio (OR): 3.32; 95% confidence interval (CI): 1.38-8.73; p = 0.01) and multi-drug therapy (OR: 2.56; 95% CI: 1.21-5.39; p = 0.01) were associated with an increased odds of VAD complication. Eighty-two (30.9%) participants experienced an ADE; 30 (11.3%) experienced a severe/serious ADE. Lipo/glycopeptide receipt, (OR: 5.28; 95% CI: 1.89-15.43; p < 0.01) and Black/African American race (OR: 4.85; 95% (CI): 1.56-15.45; p < 0.01) were associated with an increased odds of severe/serious ADE. Inclusion in the OPAT collaborative was associated with a decreased odds of severe/serious ADE (OR: 0.26; 95% CI: 0.08-0.77; p = 0.01). Fifty-eight (21.9%) patients experienced an OPAT-related ED visit and 53 (20.0%) experienced an OPAT-related rehospitalization. VAD complication (OR: 2.37; 95% (CI): 1.15-4.86, p = 0.02) and ADEs (OR: 2.19; CI: 1.13-4.22; p = 0.02) were associated with OPAT-related ED visits. ADE was associated with 90-day OPAT-related rehospitalization (OR: 3.21; (CI): 1.59-6.58; p < 0.01). Conclusion Adverse safety events and OPAT-related unscheduled care occurred often in our cohort. A structured OPAT program that includes ID pharmacist antibiotic reconciliation may reduce rates of ADEs.
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Affiliation(s)
| | - Jennifer K. Ross
- M Health Fairview University of Minnesota Medical Center, Minneapolis, MN, USA
| | | | - Michael D. Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Susan E. Kline
- M Health Fairview University of Minnesota Medical Center, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alison L. Galdys
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 250, Minneapolis, MN 55455, USA
- M Health Fairview University of Minnesota Medical Center, Minneapolis, MN, USA
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An analysis of 90-day emergency department visits after peripherally inserted central catheter (PICC) placement for prosthetic joint infection. Infect Control Hosp Epidemiol 2022; 43:1853-1858. [PMID: 35249571 DOI: 10.1017/ice.2022.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Research on complications with peripherally inserted central catheter (PICC) lines that are placed for the treatment of prosthetic joint infection (PJI) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is scarce. We investigated the timing, frequency, and risk factors for PICC complications during treatment of PJI after THA and TKA. METHODS We retrospectively queried an institutional database for THA and TKA patients from January 2015 through December 2020 that developed a PJI and required PICC placement at an academic, tertiary-care referral center. RESULTS The study included 889 patients (48.3% female) with a mean age of 64.6 years (range, 18.7-95.2) who underwent 435 THAs and 454 TKAs that were revised for PJI. The cohort had 275 90-day ED visits (30.9%), and 51 (18.5%) were PICC related. The average time from discharge to PICC ED visit was 26.2 days (range, 0.3-89.4). The most common reasons for a 90-day ED visit were issues related to the joint replacement or wound site (musculoskeletal or MSK; n = 116, 42.2%) and PICC complaints (n = 51, 18.5%). A multivariable logistic regression demonstrated that non-White race (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.24-4.04; P = .007) and younger age (OR, 0.98; 95% CI, 0.95-1.00; P = .035) were associated with PICC-related ED visits. Malposition/readjustment (41.2%) and occlusion (35.3%) were the most common PICC complications leading to ED presentation. CONCLUSIONS PICC complications are common after PJI treatment, accounting for nearly 20% of 90-day ED visits.
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Venkatraman V, Kirsch EP, Luo E, Kunte S, Ponder M, Gellad ZF, Liu B, Lee HJ, Jung SH, Haglund MM, Lad SP. Outcomes With a Mobile Digital Health Platform for Patients Undergoing Spine Surgery: Retrospective Analysis. JMIR Perioper Med 2022; 5:e38690. [PMID: 36287589 PMCID: PMC9647464 DOI: 10.2196/38690] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/26/2022] [Accepted: 09/05/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Digital health solutions have been shown to enhance outcomes for individuals with chronic medical illnesses, but few have been validated for surgical patients. The digital health platform ManageMySurgery (MMS) has been validated for spine surgery as a feasible method for patients along their surgical journey through in-app education and completion of patient-reported outcomes surveys. OBJECTIVE The aim of this study is to determine the rates of 90-day emergency room (ER) visits, readmissions, and complications in patients undergoing spine surgery using MMS compared to patients using traditional perioperative care alone. METHODS Patients undergoing spine surgery at a US-based academic hospital were invited to use MMS perioperatively between December 2017 and September 2021. All patients received standard perioperative care and were classified as MMS users if they logged into the app. Demographic information and 90-day outcomes were acquired via electronic health record review. The odds ratios of having 90-day ER visits, readmissions, mild complications, and severe complications between the MMS and non-MMS groups were estimated using logistic regression models. RESULTS A total of 1015 patients were invited, with 679 using MMS. MMS users and nonusers had similar demographics: the average ages were 57.9 (SD 12.5) years and 61.5 (SD 12.7) years, 54.1% (367/679) and 47.3% (159/336) were male, and 90.1% (612/679) and 88.7% (298/336) had commercial or Medicare insurance, respectively. Cervical fusions (559/1015, 55.07%) and single-approach lumbar fusions (231/1015, 22.76%) were the most common procedures for all patients. MMS users had a lower 90-day readmission rate (55/679, 8.1%) than did nonusers (30/336, 8.9%). Mild complications (MMS: 56/679, 8.3%; non-MMS: 32/336, 9.5%) and severe complications (MMS: 66/679, 9.7%; non-MMS: 43/336, 12.8%) were also lower in MMS users. MMS users had a lower 90-day ER visit rate (MMS: 62/679, 9.1%; non-MMS: 45/336, 13.4%). After adjustments were made for age and sex, the odds of having 90-day ER visits for MMS users were 32% lower than those for nonusers, but this difference was not statistically significant (odds ratio 0.68, 95% CI 0.45-1.02; P=.06). CONCLUSIONS This is one of the first studies to show differences in acute outcomes for people undergoing spine surgery who use a digital health app. This study found a correlation between MMS use and fewer postsurgical ER visits in a large group of spine surgery patients. A planned randomized controlled trial will provide additional evidence of whether this digital health tool can be used as an intervention to improve patient outcomes.
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Affiliation(s)
- Vishal Venkatraman
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Elayna P Kirsch
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Emily Luo
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Sameer Kunte
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | | | | | - Beiyu Liu
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, United States
| | - Hui-Jie Lee
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, United States
| | - Sin-Ho Jung
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, United States
| | - Michael M Haglund
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
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Shetty PN, Guarino GM, Zhang G, Sanghavi KK, Giladi AM. Risk Factors for Preventable Emergency Department Use After Outpatient Hand Surgery. J Hand Surg Am 2022; 47:855-864. [PMID: 35843760 DOI: 10.1016/j.jhsa.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/30/2022] [Accepted: 05/18/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Emergency department (ED) visits for postoperative concerns that could be safely addressed in outpatient clinics have an impact on cost, quality measures, and care workflows. Patient-reported data (PRD) may give unique insights into individual-level factors that predict overuse of health care resources, and guide opportunities for intervention and prevention. We investigated the relationship between preoperative PRD and preventable ED use after outpatient hand surgery to determine whether the preoperative PRD can be used to identify patients at higher odds of having preventable ED visits. METHODS All adult patients undergoing outpatient surgery at our hand center between January 1, 2018, and December 31, 2019, were included. Questionnaires, including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI) scales, were completed before surgery. We used our regional health information exchange to identify ED visits within 90 days of surgery. RESULTS Our cohort included 2,819 patients. Within 90 days after surgery, 106 (3.8%) had preventable ED visits. Race, insurance status, and transportation issues increased odds of a preventable ED visit. Multivariable models found that each 1-point increase in the preoperative PROMIS UE score was associated with 4% decreased odds of ED presentation (odds ratio, 0.96; 95% confidence interval, 0.94-0.99), and each 1-point increase in the preoperative PROMIS PI score was associated with 4% increased odds of ED presentation (odds ratio, 1.04; 95% confidence interval, 1.0-1.1). Any PROMIS UE or PI scores ≥1SDs worse than population norms increased the probability of a preventable ED visit, independent of other factors. CONCLUSIONS Worse preoperative PROMIS UE and PI scores were associated with increased odds of preventable ED visits. Preoperative PRD may allow for identification of outliers at higher risk for preventable ED use, and facilitate preventative interventions. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Pragna N Shetty
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Gianna M Guarino
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Gongliang Zhang
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Health Research Institute, Hyattsville, MD
| | - Kavya K Sanghavi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Health Research Institute, Hyattsville, MD
| | - Aviram M Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Reisener MJ, Hughes AP, Okano I, Zhu J, Arzani A, Kostas J, Shue J, Sama AA, Cammisa FP, Girardi FP, Soffin EM. Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients. J Neurosurg Spine 2022; 36:713-721. [PMID: 34861648 DOI: 10.3171/2021.8.spine21599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. METHODS The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0-10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher's exact tests) and multivariable (Wald's chi-square test) analyses. RESULTS In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20-60 mg] vs 20 mg [IQR 11-39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188-575 mg] vs 199 mg [100-372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60-135 mg] vs 60 mg [IQR 45-80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3-6] vs 5 [IQR 3-6], p = 0.33), nursing floor pain scores (4 [IQR 3-5] vs 4 [IQR 3-5], p = 0.93), or total LOS (118 hours [IQR 81-173 hours] vs 103 hours [IQR 81-132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald's chi square = 9.45, effect size -52.4, 95% confidence interval [CI] -86 to -19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald's chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald's chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). CONCLUSIONS A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.
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Affiliation(s)
- Marie-Jacqueline Reisener
- 1Department of Orthopaedic Surgery, Spine Care Institute
- 4Centrum für Muskuloskeletale Chirurgie (CMSC), Charité University Hospital, Berlin, Germany
| | | | - Ichiro Okano
- 1Department of Orthopaedic Surgery, Spine Care Institute
| | - Jiaqi Zhu
- 2Epidemiology & Biostatistics Department, and
| | - Artine Arzani
- 1Department of Orthopaedic Surgery, Spine Care Institute
| | | | - Jennifer Shue
- 1Department of Orthopaedic Surgery, Spine Care Institute
| | - Andrew A Sama
- 1Department of Orthopaedic Surgery, Spine Care Institute
| | | | | | - Ellen M Soffin
- 3Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York; and
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Karhade AV, Lavoie-Gagne O, Agaronnik N, Ghaednia H, Collins AK, Shin D, Schwab JH. Natural language processing for prediction of readmission in posterior lumbar fusion patients: which free-text notes have the most utility? Spine J 2022; 22:272-277. [PMID: 34407468 DOI: 10.1016/j.spinee.2021.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/19/2021] [Accepted: 08/09/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The increasing volume of free-text notes available in electronic health records has created an opportunity for natural language processing (NLP) algorithms to mine this unstructured data in order to detect and predict adverse outcomes. Given the volume and diversity of documentation available in spine surgery, it remains unclear which types of documentation offer the greatest value for prediction of adverse outcomes. STUDY DESIGN/SETTING Retrospective review of medical records at two academic and three community hospitals. PURPOSE The purpose of this study was to conduct an exploratory analysis in order to examine the utility of free-text notes generated during the index hospitalization for lumbar spine fusion for prediction of 90-day unplanned readmission. PATIENT SAMPLE Adult patients 18 years or older undergoing lumbar spine fusion for lumbar spondylolisthesis or lumbar spinal stenosis between January 1, 2016 and December 31, 2020. OUTCOME MEASURES The primary outcome was inpatient admission within 90-days of discharge from the index hospitalization. METHODS The predictive performance of NLP algorithms developed by using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, medical doctor (MD) (resident or attending), and allied practice professional (APP) (nurse practitioner or physician assistant) notes were assessed by discrimination, calibration, overall performance. RESULTS Overall, 708 patients were included in the study and 83 (11.7%) had 90-day inpatient readmission. In the independent testing set of patients (n=141) not used for model development, the area under the receiver operating curve of NLP algorithms for prediction of 90-day readmission using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, MD/APP notes was 0.70, 0.57, 0.57, 0.60, 0.60, and 0.49 respectively. CONCLUSION In this exploratory analysis, discharge summary, physical therapy, and case management notes had the most utility and daily MD/APP progress notes had the least utility for prediction of 90-day inpatient readmission in lumbar fusion patients among the free-text documentation generated during the index hospitalization.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Ophelie Lavoie-Gagne
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Agaronnik
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hamid Ghaednia
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Austin K Collins
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Shin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Harvard Combined Orthopaedic Residency Program, Boston, MA, USA.
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11
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Alomari S, Judy B, Weingart J, Lo SFL, Sciubba DM, Theodore N, Witham T, Bydon A. Early Outcomes of Elective Anterior Cervical Diskectomy and Fusion for Degenerative Spine Disease Correlate With the Specialty of the Surgeon Performing the Procedure. Neurosurgery 2022; 90:99-105. [PMID: 34982876 PMCID: PMC10602516 DOI: 10.1227/neu.0000000000001748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/21/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Comparative effectiveness research has a vital role in recent health reform and policies. Specialty training is one of these provider-side variables, and surgeons who were trained in different specialties may have different outcomes on performing the same procedure. OBJECTIVE To investigate the impact of spine surgeon specialty (neurosurgery vs orthopedic surgery) on early perioperative outcome measures of elective anterior cervical diskectomy and fusion (ACDF) for degenerative spine diseases. METHODS This was a retrospective, 1:1 propensity score-matched cohort study. In total, 21 211 patients were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching and subgroup analysis were performed. RESULTS In both groups (single-level/multilevel ACDF), patients operated on by neurosurgeons had longer operation time (133 vs 104 min/164 vs 138 min), shorter total hospital stay (24 vs 41 h/25 vs 46 h), and lower rates of return to operating room (0.7% vs 2.1%/0.6% vs 2.4%), nonhome discharge (1.2% vs 4.6%/1.0% vs 4.9%), discharge after postoperative day 1 (6.7% vs 11.9%/10.1% vs 18.9%), perioperative blood transfusion (0.4% vs 2.1%/0.6% vs 3.1%), and sepsis (0.2% vs 0.7%/0.1% vs 0.7%; P < .05). In the single-level ACDF group, patients operated on by neurosurgeons had lower readmission (1.9% vs 4.1%) and unplanned intubation rates (0.1% vs 1.1%; P < .05). Other outcome measures and mortality rates were similar among the 2 cohorts in both groups. CONCLUSION Our analysis found significant differences in early perioperative outcomes of patients undergoing ACDF by neurosurgeons and orthopedic surgeons. These differences might have significant clinical and cost implications for patients, physicians, program directors, payers, and health systems.
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Affiliation(s)
- Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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12
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Yin J, Mao W, Xiao X, Yu X, Li B, Chen F, Lin J, Zhou J, Zhou J, Tong Z, Ke L, Li W. Immune Dysfunction is Associated with Readmission in Survivors of Sepsis Following Infected Pancreatic Necrosis. J Inflamm Res 2021; 14:5433-5442. [PMID: 34707384 PMCID: PMC8542572 DOI: 10.2147/jir.s321507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/11/2021] [Indexed: 12/04/2022] Open
Abstract
Objective Immunosuppression is common in patients with infected pancreatic necrosis (IPN) and associated with morbidity and mortality. This study aimed to investigate the impact of immune status on mortality and readmission after hospital discharge in patients with IPN-related sepsis. Methods In this prospective observational study, eligible adult patients with IPN-related sepsis requiring ICU admission were included. Monocytic human leukocyte antigen DR (mHLA-DR), expression of regulatory T cells (Treg), and neutrophil CD88 (nCD88) were measured on the diagnosis of sepsis, ICU discharge, hospital discharge, and 15, 30, 60 days after hospital discharge. Logistic regression model was used to assess potential risk factors for readmission 60-days within the index discharge. Results A total of 53 patients were included, 13 died during hospitalization and one withdrew the consent soon after discharge. Among the survivors, a tendency of immune recovery was observed during the consecutive follow-ups, evidenced by the increased expression of mHLA-DR. Sixteen patients (41.03%) were readmitted within 60 days after the index discharge. In the multivariable regression model, APACHE II score when sepsis was diagnosed >9 and mHLA-DR at discharged <14,591 AB/C were found to be independent risk factors affecting readmission. Conclusion Immunosuppression is common in patients with IPN-related sepsis and can persist until two months after discharge. The compromised mHLA-DR level at discharge was associated with readmission within two months after discharge.
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Affiliation(s)
- Jiangtao Yin
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, People's Republic of China.,Department of Intensive Care Unit, Affiliated Hospital of Jiangsu University, Zhenjiang, People's Republic of China
| | - Wenjian Mao
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, People's Republic of China
| | - Xiaojia Xiao
- Department of Critical Care Medicine, Jinling Hospital of Southern Medical University, Nanjing, People's Republic of China
| | - Xianqiang Yu
- Southeast University School of Medicine, Nanjing, People's Republic of China
| | - Baiqiang Li
- Department of Critical Care Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Faxi Chen
- Department of Critical Care Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Jiajia Lin
- Department of Critical Care Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Jing Zhou
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, People's Republic of China
| | - Jing Zhou
- Southeast University School of Medicine, Nanjing, People's Republic of China
| | - Zhihui Tong
- Department of Critical Care Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, People's Republic of China.,Department of Critical Care Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
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