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Escalera C, Rodarte P, Navarro RA, Bolanos AA, Buerba RA, Payares-Lizano M, Santos EM, Gonzalez MH, Jimenez R. The American Association of Latino Orthopaedic Surgeons: Our History, Achievements, and Future Goals. J Bone Joint Surg Am 2024; 106:748-754. [PMID: 37820271 DOI: 10.2106/jbjs.23.00524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
ABSTRACT The mission of the American Association of Latino Orthopaedic Surgeons (AALOS) is to provide collegiality, advancement, education, and social justice for Latino orthopaedic surgeons and the minority populations they represent. We strive to enhance diversity within the field of orthopaedic surgery by increasing the visibility of AALOS, highlighting its core focus, and emphasizing its mission. The purposes of this article are to discuss the need for this organization and highlight its history and future goals. As AALOS recently celebrated its 15-year anniversary, we are excited to continue advancing the field of orthopaedic surgery and improving our patients' care.
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Affiliation(s)
| | - Patricia Rodarte
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ronald A Navarro
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | | | | | | | - Erick M Santos
- South Central Texas Bone and Joint Center, Corpus Christi, Texas
| | | | - Ramon Jimenez
- Orthopaedic Med-Legal Evaluations, Monterey, California
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Ghahremani JS, Ogi JE, Kody MT, Navarro RA. Readability of Online Patient Education Materials for Shoulder Instability Surgery in English and Spanish. J Shoulder Elbow Surg 2024:S1058-2746(24)00230-1. [PMID: 38582252 DOI: 10.1016/j.jse.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/24/2024] [Accepted: 02/12/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Online patient education materials exist to inform patient medical decisions, yet the average adult in the United States reads at an eighth-grade level and 50% of Medicaid patients read at or below a fifth-grade level. To appropriately meet U.S. health literacy needs, the American Medical Association and National Institutes of Health recommend that patient education materials not exceed a sixth-grade level. The purpose of this study was to assess and compare the readability of English and Spanish online patient education materials pertaining to shoulder instability surgery. METHODS Google searches of the terms "shoulder instability surgery" and "cirugía de inestabilidad de hombro'' were conducted to include 25 eligible OPEMs per language. English OPEM readability was calculated using Flesch-Kincaid Grade Level, Flesch Reading Ease, Flesch Reading Ease Grade Level, Gunning-Fog Index, Coleman-Liau Index, and Simple Measure of Gobbledygook. Spanish OPEM readability was assessed using Fernandez-Huerta Index (the Spanish equivalent of Flesch Reading Ease), Fernandez-Huerta Index Grade Level, Gutiérrez de Polini's Fórmula de comprensibilidad, and INFLESZ. RESULTS Readability index analysis revealed that the mean Flesch Reading Ease of English online patient education materials was significantly lower than the mean Fernandez-Huerta Index of Spanish online patient education materials. English materials were also found to be written at a significantly higher grade level than Spanish materials. CONCLUSIONS Shoulder instability surgery online patient education materials in both English and Spanish are written at higher reading levels than recommended by the AMA and NIH, though Spanish online patient education materials were more readable on average.
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Affiliation(s)
- Jacob S Ghahremani
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Jenna E Ogi
- University of Southern California, Los Angeles, CA, USA
| | - Michael T Kody
- Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Ronald A Navarro
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA; Department of Orthopaedic Surgery, Kaiser Permanente South Bay Medical Center, Harbor City, CA, USA
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Mazotti LA, Amorelli DA, Navarro RA, Hyderi AA, Kanter MH, Lupi CS. Clinical Assessment Specialists: A New Faculty Role to Improve Clerkship Assessment. Perm J 2024; 28:76-80. [PMID: 38037372 PMCID: PMC10940249 DOI: 10.7812/tpp/23.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Ambulatory clerkships, including longitudinal integrated clerkships (LICs), face challenges to assessment, including time pressure and clinical demands on preceptors. High-quality clinical assessment is critical to implementing competency-based medical education, generating valid grades, and supporting learning. This importance is further heightened with the new pass/fail scoring for US Medical Licensing Exam Step 1, discontinuation of US Medical Licensing Exam Step 2 Clinical Skills, and the growing concern for bias in assessment. METHODS The Kaiser Permanente Bernard J. Tyson School of Medicine's LIC spans the first 2 years with 50 students per class. In 2021-2022, the authors created a new faculty role, the clinical assessment specialist (CASp). CASps are highly trained clinical teachers who directly observe clerkship students in the ambulatory setting, provide feedback, and complete competency-based assessment forms. RESULTS CASps completed 186 assessments of first-year (Y1) LIC students and 333 assessments of second-year (Y2) LIC students. Y2 students achieved average higher milestones and were rated as requiring less supervision compared to Y1 students. Y1 students rated CASps more favorably than Y2 students. Preceptors rated the contribution of CASps similarly across both years. Clerkship directors described benefits including identification of at-risk students and value of augmenting preceptor assessments. DISCUSSION The CASp role may offer an innovative way to generate valid assessment of student performance, offset clinical pressures faced by preceptors, identify at-risk students, and mitigate bias, especially in an LIC. Future studies may examine assessment validity, including use in summative assessment. CONCLUSION CASps are an innovative approach to clinical clerkship assessment.
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Affiliation(s)
- Lindsay A Mazotti
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- The Permanente Medical Group, Oakland, CA, USA
| | - Delores A Amorelli
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Ronald A Navarro
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Abbas A Hyderi
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Michael H Kanter
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Carla S Lupi
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Navarro RA. CORR Insights®: Are Social Deprivation and Low Traditional Health Literacy Associated With Higher PROMIS CAT Completion in Orthopaedic Surgery? Clin Orthop Relat Res 2024; 482:455-457. [PMID: 37889859 PMCID: PMC10871776 DOI: 10.1097/corr.0000000000002898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023]
Affiliation(s)
- Ronald A. Navarro
- Kaiser Permanente School of Medicine, Orthopaedic Surgery, Southern California Permanente Medical Group, Harbor City, CA, USA
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Prentice HA, Harris JE, Sucher K, Fasig BH, Navarro RA, Okike KM, Maletis GB, Guppy KH, Chang RW, Kelly MP, Hinman AD, Paxton EW. Improvements in Quality, Safety and Costs Associated with Use of Implant Registries Within a Health System. Jt Comm J Qual Patient Saf 2024:S1553-7250(24)00040-0. [PMID: 38368191 DOI: 10.1016/j.jcjq.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Clinical quality registries (CQRs) are intended to enhance quality, safety, and cost reduction using real-world data for a self-improving health system. Starting in 2001, Kaiser Permanente established several medical device CQRs as a quality improvement initiative. This report examines the contributions of these CQRs on improvement in health outcomes, changes in clinical practice, and cost-effectiveness over the past 20 years. METHODS Eight implant registries were instituted with standardized collection from the electronic health record and other institutional data sources of patient characteristics, medical comorbidities, implant attributes, procedure details, surgical techniques, and outcomes (including complications, revisions, reoperations, hospital readmissions, and other utilization measures). A rigorous quality control system is in place to improve and maintain the quality of data. Data from the Implant Registries form the basis for multiple quality improvement and patient safety initiatives to minimize variation in care, promote clinical best practices, facilitate recalls, perform benchmarking, identify patients at risk, and construct reports about individual surgeons. RESULTS Following the inception of the Implant Registries, there was an observed (1) reduction in opioid utilization following orthopedic procedures, (2) reduction in use of bone morphogenic protein during lumbar fusion allowing for cost savings, (3) reduction in allograft for anterior cruciate ligament reconstruction and subsequent decrease in organizationwide revision rates, (4) cost savings through expansion of same-day discharge programs for joint arthroplasty, (5) increase in the use of cement fixation in the hemiarthroplasty treatment of hip fracture, and (6) organizationwide discontinuation of an endograft device associated with a higher risk for adverse outcomes following endovascular aortic aneurysm repair. CONCLUSION The use of Implant Registries within our health system, along with clinical leadership and organizational commitment to a learning health system, was associated with improved quality and safety outcomes and reduced costs. The exact mechanisms by which such registries affect health outcomes and costs require further study.
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Kody MT, Anavian J, Navarro RA, Lederman ES, Ganokroj P, Whalen RJ, Apostolakos JM, Provencher CMT. Management of Glenoid Bone Loss in Shoulder Instability: Where We Are in 2023. Instr Course Lect 2024; 73:691-707. [PMID: 38090934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The management of glenoid bone loss in shoulder instability can be challenging. Although shoulder instability can often be managed with arthroscopic soft-tissue procedures alone, the extent of glenoid bone loss and bipolar bone defects may require bone augmentation procedures for restoration of stability. In this setting, patient evaluation, examination, treatment options, and surgical pearls are vital. Furthermore, a treatment algorithm is established to guide both indications and the technical application of procedures including Bankart repair with remplissage, Latarjet procedure, and glenoid bone graft options. The limitations, complications, and current research pertinent to each treatment assist in guiding treatment.
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Hinman AD, Royse KE, Chan PH, Paxton EW, Navarro RA. Association Between Race/Ethnicity and 90-Day Emergency Department Visits in Patients Undergoing Elective Total Knee Arthroplasty or Total Hip Arthroplasty in a Universally Insured Population. J Arthroplasty 2023; 38:2210-2219.e1. [PMID: 37479196 DOI: 10.1016/j.arth.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Research has identified disparities in returns to care by race/ethnicity following primary total joint arthroplasty. We sought to identify risk factors for 90-day emergency department (ED) returns following primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) for these populations. METHODS Black, Hispanic, and non-Hispanic White patients who underwent elective primary unilateral TKA and THA in an integrated US healthcare system were identified. Risk factors for 90-day postoperative ED visits including patient demographics, household income and education, comorbidities, preoperative healthcare utilization, and copay data were identified with multivariable logistic regression. RESULTS Postoperative 90-day ED visits occurred in 13.3% of 79,565 TKA patients (17.2% Black; 14.9% Hispanic; 12.5% White) and 11.0% of THA patients (13.4% Black; 12.1% Hispanic; 10.7% White). Across racial/ethnic categories, patients who had an ED visit within 1 year of their TKA or THA date were more likely to have a 90-day ED return. Shared risk factors for TKA patients were chronic lung disease and outpatient utilization (25th and 75th percentile), while peripheral vascular disease was a shared risk factor for THA patients. Risk factors for multiple races of TKA and THA patients included depression, drug abuse, and psychosis. Prior copay for White (TKA) and Hispanic (TKA and THA) patients was protective, while preoperative primary care was protective for Black THA patients. CONCLUSION Future strategies to reduce postoperative ED returns should include directed patient outreach for patients who had ED visits and mental health in the year prior to TKA and THA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Adrian D Hinman
- Department of Orthopaedics, The Permanente Medical Group, San Leandro, California
| | - Kathryn E Royse
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Priscilla H Chan
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Ronald A Navarro
- Department of Orthopaedics, Southern California Permanente Medical Group, South Bay, California
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Hachadorian M, Chang RN, Prentice HA, Paxton EW, Rao AG, Navarro RA, Singh A. Association between same-day discharge shoulder arthroplasty and risk of adverse events in patients with American Society of Anesthesiologists classification ≥3: a cohort study. J Shoulder Elbow Surg 2023; 32:e556-e564. [PMID: 37268285 DOI: 10.1016/j.jse.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Same-day discharge for shoulder arthroplasty (SA) is well-supported in the literature; however, most studies have focused on healthier patients. Indications for same-day discharge SA have expanded to include patients with more comorbidities, but safety of same-day discharge in this population remains unknown. We sought to compare outcomes following same-day discharge vs. inpatient SA in a cohort of patients considered higher risk for adverse events, defined as an American Society of Anesthesiologists (ASA) classification of ≥3. METHODS Data from Kaiser Permanente's SA registry were utilized to conduct a retrospective cohort study. All patients with an ASA classification of ≥3 who underwent primary elective anatomic or reverse SA in a hospital from 2018 to 2020 were included. The exposure of interest was in-hospital length of stay: same-day discharge vs. ≥1-night hospital inpatient stay. The likelihood of 90-day post-discharge events, including emergency department (ED) visit, readmission, cardiac complication, venous thromboembolism, and mortality, was evaluated using propensity score-weighted logistic regression with noninferiority testing using a margin of 1.10. RESULTS The cohort included a total of 1814 SA patients, of whom 1005 (55.4%) had same-day discharge. In propensity score-weighted models, same-day discharge was not inferior to an inpatient stay SA regarding 90-day readmission (odds ratio [OR] = 0.64, one-sided 95% upper bound [UB] = 0.89) and overall complications (OR = 0.67, 95% UB = 1.00). We lacked evidence in support of noninferiority for 90-day ED visit (OR = 0.96, 95% UB = 1.18), cardiac event (OR = 0.68, 95% UB = 1.11), or venous thromboembolism (OR = 0.91, 95% UB = 2.15). Infections, revisions for instability, and mortality were too rare to evaluate using regression analysis. CONCLUSIONS In a cohort of over 1800 patients with an ASA of ≥3, we found same-day discharge SA did not increase the likelihood of ED visits, readmissions, or complications compared with an inpatient stay, and same-day discharge was not inferior to an inpatient stay with regard to readmissions and overall complications. These findings suggest that it is possible to expand indications for same-day discharge SA in the hospital setting.
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Affiliation(s)
- Michael Hachadorian
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Richard N Chang
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, CA, USA
| | - Heather A Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, CA, USA
| | - Elizabeth W Paxton
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, CA, USA
| | - Anita G Rao
- Department of Orthopaedic Surgery, Northwest Permanente Medical Group, Vancouver, WA, USA
| | - Ronald A Navarro
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, South Bay, CA, USA
| | - Anshuman Singh
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, San Diego, CA, USA.
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Lin CC, Semelsberger S, Saeed AA, Weiss J, Navarro RA, Gianakos AL. Perception of Debt During Resident Education-A Systematic Review. Perm J 2023; 27:99-109. [PMID: 37350090 PMCID: PMC10502380 DOI: 10.7812/tpp/23.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Debt is a common issue among medical residents in the United States. This review attempts 1) to evaluate the level of debt among residents, 2) to assess perceptions toward debt among residents, 3) to determine debt-management options pursued, and 4) to gauge whether levels of debt affect resident career choices. A systematic literature search of articles published between January 2012 and January 2022 in the MEDLINE, EMBASE, and Cochrane databases was performed. The combination of search terms of (financial literacy OR debt) AND (residency OR graduate medical education) were utilized. Primary outcome measures assessed were the levels of debt and perceptions toward the debt. Secondary outcome measures were debt-management options pursued and whether debt affected career choices for residents. Twenty-one studies evaluating a total of 15,585 residents were included in this systematic review. Levels of debt greater than $200,000 were not uncommon across residents and debt burdens are increasing. Greater levels of debt are associated with increased stress and anxiety. Residents reported multiple debt-management options pursued, including loan forbearance, moonlighting, income-based repayment models, military financial support, and loan forgiveness programs. Those with increased levels of debt were less likely to pursue subspecialty training and academic employment positions. The findings conclude that residents carry a substantial amount of debt, and it is a common source of stress and anxiety. Although there are many different avenues that are pursued for debt repayment, levels of debt appear to affect decisions to pursue subspecialty training and to pursue academic positions. Strategies or programs aimed at reducing the debt burden felt by residents could be of great value.
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Affiliation(s)
- Charles C Lin
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | | | - Ali Al Saeed
- Lake Erie College of Osteopathic Medicine, Lake Erie, PA, USA
| | - Jennifer Weiss
- Department of Orthopaedic Surgery, Kaiser Permanente, Los Angeles, CA, USA
| | - Ronald A Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente, Los Angeles, CA, USA
| | - Arianna L Gianakos
- Department of Orthopaedic Surgery, Yale Medicine, Orthopaedics, and Rehabilitation, New Haven, CT, USA
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Dillon MT, Beleckas CM, Navarro RA. Techniques for Managing the Subscapularis and Addressing Failures of the Tendon in Anatomic Total Shoulder Arthroplasty. Orthopedics 2023; 46:e264-e272. [PMID: 37216563 DOI: 10.3928/01477447-20230517-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Anatomic total shoulder arthroplasty (aTSA) is an accepted treatment for a variety of degenerative conditions of the glenohumeral joint. The manner in which the subscapularis tendon is handled during the approach in aTSA is not universally agreed on. Failure of the repair after aTSA has been shown to be associated with poorer outcomes in some cases. There is no consensus on how to treat failures, as all techniques described in the literature demonstrate shortcomings. The purpose of this review is to evaluate the methods of handling the tendon in aTSA and to review options for treating failure following surgery. [Orthopedics. 2023;46(5):e264-e272.].
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Orvets ND, Chan PH, Taylor JM, Prentice HA, Navarro RA, Garcia IA. Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients. J Shoulder Elbow Surg 2023; 32:1893-1900. [PMID: 37075936 DOI: 10.1016/j.jse.2023.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/03/2023] [Accepted: 03/22/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Reverse total shoulder arthroplasty (RTSA), initially indicated for cuff tear arthropathy, is increasingly used to treat elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff. This is often done to avoid revision surgery in elderly patients for rotator cuff failure with anatomic total shoulder arthroplasty (TSA) despite traditionally good outcomes of TSA. We sought to determine whether there was a difference in outcomes in patients aged ≥70 years who received RTSA vs. TSA for GHOA. METHODS A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged ≥70 years who underwent primary shoulder arthroplasty for GHOA with an intact rotator cuff were included (2012-2021). RTSA was compared with TSA. Multivariable Cox proportional hazard regression was used to evaluate all-cause revision risk during follow-up, whereas multivariable logistic regression was used to evaluate 90-day emergency department (ED) visits and 90-day readmissions. RESULTS The final study sample comprised 685 RTSA patients and 3106 TSA patients. The mean age was 75.8 years (standard deviation, 4.6 years), and 43.4% of patients were men. After accounting for confounders, we observed no significant difference in all-cause revision risk for RTSA vs. TSA (hazard ratio, 0.79; 95% confidence interval [CI], 0.39-1.58). The most common reason for revision following RTSA was glenoid component loosening (40.0%). Over half of revisions following TSA were for rotator cuff tear (54.0%). No difference based on procedure type was observed in the likelihood of 90-day ED visits (odds ratio, 0.94; 95% CI, 0.71-1.26) and 90-day readmissions (odds ratio, 1.32; 95% CI, 0.83-2.09). CONCLUSION RTSA and TSA for GHOA with an intact rotator cuff in patients aged ≥70 years had a similar revision risk, as well as a similar likelihood of 90-day ED visits and readmissions. Although revision risk was similar, the most common causes of revision were different, with rotator cuff tears in TSA patients and glenoid component loosening in RTSA patients.
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Affiliation(s)
- Nathan D Orvets
- Department of Orthopedic Surgery, Northwest Permanente Medical Group, Portland, OR, USA.
| | - Priscilla H Chan
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, CA, USA
| | - Jeremiah M Taylor
- Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Heather A Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, CA, USA
| | - Ronald A Navarro
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, South Bay, CA, USA
| | - Ivan A Garcia
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Baldwin Park, CA, USA
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Navarro RA, Chan PH, Prentice HA, Pearl M, Matsen 3rd FA, McElvany MD. Use of Preoperative CT Scans and Patient-Specific Instrumentation May Not Improve Short-Term Adverse Events After Shoulder Arthroplasty: Results from a Large Integrated Health-Care System. JB JS Open Access 2023; 8:e22.00139. [PMID: 37415725 PMCID: PMC10319369 DOI: 10.2106/jbjs.oa.22.00139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Ongoing innovation leads to a continuous influx of new technologies related to shoulder arthroplasty. These are made available to surgeons and marketed to both health-care providers and patients with the hope of improving outcomes. We sought to evaluate how preoperative planning technologies for shoulder arthroplasty affect outcomes. Methods This was a retrospective cohort study conducted using data from an integrated health-care system's shoulder arthroplasty registry. Adult patients who underwent primary elective anatomic or reverse total shoulder arthroplasty (2015 to 2020) were identified. Preoperative planning technologies were identified as (1) a computed tomography (CT) scan and (2) patient-specific instrumentation (PSI). Multivariable Cox regression and logistic regression were used to compare the risk of aseptic revision and 90-day adverse events, respectively, between procedures for which technologies were and were not used. Results The study sample included 8,117 procedures (in 7,372 patients) with an average follow-up of 2.9 years (maximum, 6 years). No reduction in the risk of aseptic revision was observed for patients having either preoperative CT scans (hazard ratio [HR] = 1.22; 95% confidence interval [CI] = 0.87 to 1.72) or PSI (HR = 1.44; 95% CI = 0.71 to 2.92). Patients having CT scans had a lower likelihood of 90-day emergency department visits (odds ratio [OR] = 0.84; 95% CI = 0.73 to 0.97) but a higher likelihood of 90-day venous thromboembolic events (OR = 1.79; 95% CI = 1.18 to 2.74). Patients with PSI use had a higher likelihood of 90-day deep infection (OR = 7.74; 95% CI = 1.11 to 53.94). Conclusions We found no reduction in the risk of aseptic revision with the use of these technologies. Patients having CT scans and PSI use had a higher likelihood of venous thromboembolism and deep infection, respectively. Ongoing research with extended follow-up is being conducted to further examine the effects of these technologies on patient outcomes. Level of Evidence Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ronald A. Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente South Bay Medical Center, Southern California Permanente Medical Group, Harbor City, California
| | - Priscilla H. Chan
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Heather A. Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Michael Pearl
- Department of Orthopaedic Surgery, Kaiser Permanente Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, California
| | - Frederick A. Matsen 3rd
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Matthew D. McElvany
- Department of Orthopaedic Surgery, Kaiser Permanente Santa Rosa Medical Center, The Permanente Medical Group, Santa Rosa, California
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Fierro SX, Jardaly AH, Vatsia SK, Williams MD, Taunton JD, Gruenberger EH, Navarro RA, Mehran N, Ponce BA. Diversity in Orthopaedic Surgery Residencies Based on Allopathic Medical School Affiliation. JB JS Open Access 2023; 8:JBJSOA-D-22-00113. [PMID: 37153691 PMCID: PMC10155896 DOI: 10.2106/jbjs.oa.22.00113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Orthopaedic surgery is one of the most competitive and least diverse specialties in medicine. Affiliation of an orthopaedics with an allopathic medical school impacts research opportunities and early exposure to clinical orthopaedics. The purpose of this study is to examine the potential effect allopathic medical school affiliation has on orthopaedic surgery resident demographics and academic characteristics. Methods All 202 Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedics programs were divided into 2 groups: Group 1 consisted of residency programs without an affiliated allopathic medical school, and Group 2 consisted of programs with an affiliated allopathic medical school. Affiliations were determined by cross-referencing the ACGME residency program list with the medical school list published by Association of American Medical Colleges (AAMC). Program and resident characteristics were then compiled using AAMC's Residency Explorer including region, program setting, number of residents, and osteopathic recognition. Resident characteristics included race, gender, experiences (work, volunteer, and research), peer-reviewed publications, and US Medical Licensing Examination Step 1 scores. Results Of the 202 ACGME-accredited orthopaedics residencies, Group 1 had 61 (30.2%) programs, and Group 2 had 141 (69.8%) programs. Group 2 had larger programs (4.9 vs. 3.2 resident positions/year; p < 0.001) and 1.7 times the number of residency applicants (655.8 vs. 385.5; p < 0.001). Most Group 2 residents were allopathic medical school graduates, 95.5%, compared with 41.6% in Group 1. Group 1 had 57.0% osteopathic medical school graduates, compared with 2.9% in Group 2. There were 6.1% more White residents in Group 1 residencies (p = 0.025), and Group 2 residencies consisted of 3.5% more Black residents in relation to Group 1 (p = 0.03). Academic performance metrics were comparable between the 2 groups (p > 0.05). Conclusion This study demonstrated that candidates who successfully match into an orthopaedic surgery residency program achieve high academic performance, regardless of whether the program was affiliated with an allopathic medical school. Differences may be influenced by increased representation of minority faculty, greater demand for allopathic residents, or stronger emphasis on promotion of diversity in those residency programs. Availability of Data and Material Available on reasonable request. Level of Evidence Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Samir X. Fierro
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California
| | - Achraf H. Jardaly
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, Missouri
| | | | | | - Jacob D. Taunton
- Hughston Foundation, Hughston Clinic, Columbus, Georgia
- Jack Hughston Memorial Hospital Orthopaedic Surgery Residency Program, Phenix City, Alabama
| | | | - Ronald A. Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente, Pasadena, California
| | - Nima Mehran
- Department of Orthopaedic Surgery, Kaiser Permanente, Pasadena, California
| | - Brent A. Ponce
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, Missouri
- E-mail address for B. A. Ponce:
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Gupta R, Jung J, Johnston TR, Wright DJ, Uong J, Lim PK, Shafiq B, Navarro RA. Surgeon-Specific Factors Have a Larger Impact on Decision-Making for the Management of Proximal Humerus Fractures than Patient-Specific Factors: A Prospective Cohort Study. J Shoulder Elbow Surg 2023:S1058-2746(23)00025-3. [PMID: 36690172 DOI: 10.1016/j.jse.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is significant variability both in how proximal humerus fractures (PHFs) are treated and the ensuing patient outcomes. The purpose of this study was to investigate which surgeon- and patient-specific factors contribute to decision-making in the treatment of adult PHFs. We hypothesized that orthopedic sub-specialty training creates inherent bias and plays an important role in management algorithms for PHFs. METHODS We performed a prospective cohort investigation in two groups of surgeons - traumatologists (N=25) and shoulder & elbow/sports surgeons (SES) (N=26) - and asked them to provide treatment recommendations for 30 distinct clinical cases with standardized radiographic and clinical data. This is a population-based sample of surgeons who take trauma call and treat PHFs with different sub-specializations and practice settings including academic, hospital-employed, and private. Surgeons characterized based on subspecialty (trauma vs. SES), experience level (>10 vs. ≤10-years), and employment type (hospital- vs. non-hospital-employed). Chi-square analyses, logistic mixed-effects modeling, and relative importance analysis were used to evaluate the data. RESULTS Of the patient-specific factors, we found that the management of PHFs is largely dependent on initial radiographs obtained. Traumatologists were more likely to offer open reduction internal fixation (ORIF) and less likely to offer arthroplasty: 69% ORIF (traumatologists) versus 51% ORIF (SES, p<0.001), 8% arthroplasty (traumatologists) versus 17% (SES, p<0.001). Traumatologists were less likely to change from operative (either ORIF or arthroplasty) to non-operative management compared to SES surgeons when presented with additional patient demographic data. Surgeon-specific factors contributed to more than one-half of the variability in decision-making of PHF management while patient-specific factors contributed to about one-third of the variability in decision-making. CONCLUSIONS As physicians strive to advance the treatment for PHFs and optimize patient outcomes, our findings highlight the complex overlap between surgeon-, fracture-, and patient-specific factors in the final decision-making process.
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Affiliation(s)
- Ranjan Gupta
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA.
| | - James Jung
- Department of Orthopaedic Surgery, Kaiser Permanente- Pasadena, CA, USA
| | - Tyler R Johnston
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA
| | - David J Wright
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA
| | - Jennifer Uong
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA
| | - Philip K Lim
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins University- Baltimore, MD, USA
| | - Ronald A Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente- Pasadena, CA, USA
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15
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Prentice HA, Chan PH, Reddy NC, Navarro RA, Namba RS, Paxton EW. Does Aseptic Revision Risk Differ for Primary Total Knee Arthroplasty Patients Who Have and Do not Have a Prior Primary or Revision Arthroplasty? J Arthroplasty 2023; 38:43-50.e1. [PMID: 35985538 DOI: 10.1016/j.arth.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We sought to evaluate the risk of aseptic revision in total knee arthroplasty (TKA) patients who have and do not have a history of primary or revision arthroplasty of a different major joint. METHODS We conducted a matched cohort study using data from Kaiser Permanente's arthroplasty registries. Patients who underwent primary unilateral TKA (index knee) were identified (2009-2018). Two matches based on exposure history were performed: (1) 33,714 TKAs with a history of primary arthroplasty of a different joint (contralateral knee, either hip, and/or either shoulder) were matched to 67,121 TKAs without an arthroplasty history and (2) 597 TKAs with a history of aseptic revision in a different joint were matched to 1,190 TKAs with a history of a prior arthroplasty in a different joint, but without any revision. After the matches were performed, Cox regressions were used to evaluate aseptic revision risk of the index knee using the no history groups as the reference in regression models. RESULTS No difference in aseptic revision risk for the index knee was observed when comparing patients who had a prior primary arthroplasty in a different joint to those who did not have an arthroplasty history (hazard ratio = 0.95, 95% CI = 0.86-1.06). Those patients who did not have any prior aseptic revision history in a different joint had higher risk of aseptic revision in the index knee (hazard ratio = 2.06, 95% CI = 1.17-3.63). CONCLUSION Patients who had a prior revision history had over a 2-fold higher risk of aseptic revision in the index knee, warranting close surveillance of these patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Heather A Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Priscilla H Chan
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Nithin C Reddy
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, California
| | - Ronald A Navarro
- Department of Orthopaedics, Southern California Permanente Medical Group, South Bay, California
| | - Robert S Namba
- Department of Orthopaedics, Southern California Permanente Medical Group, Irvine, California
| | - Elizabeth W Paxton
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
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16
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Navarro RA, Hsu A, Wu J, Mellano C, Sievers D, Alfaro D, Foroohar A. Complications in Olecranon Fracture Surgery: A Comparison of Tension Band Vs. Plate Osteosynthesis. Arch Bone Jt Surg 2022; 10:863-870. [PMID: 36452422 PMCID: PMC9702017 DOI: 10.22038/abjs.2021.59214.2926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/13/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND The purpose of this study is to compare the incidence of complications associated with tension band wiring (TBW) versus plate osteosynthesis (POS) in the treatment of olecranon fractures. METHODS We performed a retrospective cohort study of operatively treated adult olecranon fractures from an integrated healthcare system by multiple surgeons from January 2008 to December 2011. Patients were divided into two cohorts: fractures fixed using the tension band technique and fractures fixed using plate osteosynthesis. The study was limited to the Orthopedic Trauma Association classification of olecranon fracture type 21-B1, with subtypes 1-3. Outcome measures were loss of fracture fixation requiring revision, postoperative infection, stiffness requiring surgery, and symptomatic hardware removal (HWR). Univariate and multivariable logistic regressions were performed to test the associations between the type of internal fixation and outcomes. RESULTS A total of 321 olecranon fractures were included (median age: 61 years old, 57 % female); 153 participants were treated with TBW, and 168 patients with POS. There was one failure in the TBW group and two in the POS group (P=0.62). There were no significant differences in the infection rates (TBW 5%, POS 9%, P=0.20) and no reoperations for stiffness. The HWR occurred significantly more often in TBW (29%) than in POS (14%) (OR=0.39, P=0.001). The association between POS and decreased HWR remained highly significant (OR=0.40, P=0.003) after adjusting for clinical variables. CONCLUSION In this large study comparing POS and TBW for 21-B1 olecranon fractures, no difference in fixation failure, infection, or postoperative stiffness was noted. A significantly greater risk of symptomatic hardware occurred in TBW. These findings may assist surgeons and patients in considering the risks and benefits of TBW and POS as treatment options for displaced olecranon fractures.
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Affiliation(s)
- Ronald A. Navarro
- Southern California Permanente Medical Group,Kaiser Permanente, South Bay Medical Center, Harbor City, CA, USA
| | - Albert Hsu
- Southern California Permanente Medical Group, Kaiser Permanente, Downey Medical Center, Downey, California, USA
| | - Jun Wu
- Division of Biostatistics, Kaiser Permanente Department of Research and Evaluation, Pasadena, California, USA
| | - Christen Mellano
- Coastline Orthopaedic Associates, Fountain Valley, California, USA
| | - Dennis Sievers
- Kaiser Permanente School of Medicine, Pasadena, California, USA
| | - David Alfaro
- Kaiser Permanente School of Medicine, Pasadena, California, USA
| | - Abtin Foroohar
- Upper Extremity Surgeon, Kaiser Permanente, South Bay Medical Center, Harbor City, California, USA
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17
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Foroohar A, Prentice HA, Burfeind WE, Navarro RA, Mirzayan R, Zeltser DW. Radial head arthroplasty: a descriptive study of 970 patients in an integrated health care system. J Shoulder Elbow Surg 2022; 31:1242-1253. [PMID: 35093522 DOI: 10.1016/j.jse.2021.12.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Radial head arthroplasty (RHA) is commonly performed for isolated comminuted radial head fractures and in conjunction with traumatic elbow instability. However, there is a paucity of literature directly describing the characteristics and outcomes of patients who undergo RHA in a community-based setting. We describe a cohort of 970 RHA performed in the California regions of a US integrated health care system over a 9-year period. Patient demographics, implant selection, 90-day acute postoperative events, and cumulative reoperation/revision rates are included. METHODS Patients aged ≥18 years who underwent primary RHA were identified (2009-2017). Patient characteristics and demographics, including age, body mass index, gender, diabetes status, American Society of Anesthesiologists (ASA) classification, primary diagnosis, and concomitant procedures were described. Crude cumulative revision and reoperation probabilities were calculated as 1 minus the Kaplan-Meier estimator, with follow-up time calculated as the time from the index RHA to revision/reoperation date for those with the outcome of interest and time from index RHA to censoring date (eg, date of death, health care termination, study end date [March 31, 2018]) for those without the outcome. Ninety-day postoperative incidence of emergency department (ED) visit, readmission, and mortality was calculated as the number of patients with the event of interest over the number of patients at risk. RESULTS A total of 970 patients underwent primary unilateral RHA by 205 surgeons during the study period. Annual procedure volume increased from 53 procedures in 2009 to 157 procedures in 2017. More patients were female, without diabetes, and had an ASA classification of 1 or 2. Fracture was the predominant indication for RHA (98.4%) and more than half (54.3%) had concomitant procedures performed. Most implants were press fit (63.2%) over loose fit, and >90% were monopolar. Three-year cumulative revision and reoperation probabilities following RHA were 6.5% (95% confidence interval [CI] = 5.0%-8.5%) and 8.2% (95% CI = 6.5%-10.3%), respectively. Revisions and reoperations tended to occur within the first postoperative year. Of the 970 RHA patients, 83 (8.5%) had a 90-day ED visit, 58 (6.0%) had a 90-day readmission, and 1 (0.1%) died within a 90-day postoperative period. CONCLUSION This large cohort of RHA patients provides information about the practice of RHA at large and in the community. Surgeons are performing more RHA over time and choosing press fit stems more often. Revisions and reoperations tended to occur early. Readmission and ED visits were low but not negligible, with pain being the most common reason for ED visit.
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Affiliation(s)
- Abtin Foroohar
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, South Bay, CA, USA
| | | | | | - Ronald A Navarro
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, South Bay, CA, USA
| | - Raffy Mirzayan
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Baldwin Park, CA, USA
| | - David W Zeltser
- Department of Orthopedic Surgery, The Permanente Medical Group, San Francisco, CA, USA
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18
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Zheng C, Duffy J, Liu ILA, Sy LS, Chen W, Qian L, Navarro RA, Ryan DS, Kim SS, Mercado C, Jacobsen SJ. Risk for Shoulder Conditions After Vaccination: A Population-Based Study Using Real-World Data. Ann Intern Med 2022; 175:634-643. [PMID: 35313110 PMCID: PMC9117507 DOI: 10.7326/m21-3023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although shoulder conditions have been reported as an adverse event after intramuscular vaccination in the deltoid muscle, epidemiologic data on shoulder conditions after vaccination are limited. OBJECTIVE To estimate the risk for shoulder conditions after vaccination and assess possible risk factors. DESIGN Retrospective cohort study. SETTING Kaiser Permanente Southern California, a large integrated health care organization. PARTICIPANTS Kaiser Permanente Southern California members aged 3 years or older who had an intramuscular vaccination administered in the deltoid muscle between 1 April 2016 and 31 December 2017. MEASUREMENTS A natural language processing (NLP) algorithm was used to identify potential shoulder conditions among vaccinated persons with shoulder disorder diagnosis codes. All NLP-identified cases were manually chart confirmed on the basis of our case definition. The characteristics of vaccinated persons with and without shoulder conditions were compared. RESULTS Among 3 758 764 administered vaccinations, 371 cases of shoulder condition were identified, with an estimated incidence of 0.99 (95% CI, 0.89 to 1.09) per 10 000 vaccinations. The incidence was 1.22 (CI, 1.10 to 1.35) for the adult (aged ≥18 years) and 0.05 (CI, 0.02 to 0.14) for the pediatric (aged 3 to 17 years) vaccinated populations. In the adult vaccinated population, advanced age, female sex, an increased number of outpatient visits in the 6 months before vaccination, lower Charlson Comorbidity Index, and pneumococcal conjugate vaccine were associated with a higher risk for shoulder conditions. Among influenza vaccines, quadrivalent vaccines were associated with an increased risk for shoulder conditions. Simultaneous administration of vaccines was associated with a higher risk for shoulder conditions among elderly persons. LIMITATION Generalizability to other health care settings, use of administrative data, and residual confounding. CONCLUSION These population-based data suggest a small absolute risk for shoulder conditions after vaccination. Given the high burden of shoulder conditions, clinicians should pay attention to any factors that may further increase risks. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.
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Affiliation(s)
- Chengyi Zheng
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California (C.Z., I.A.L., L.S.S., W.C., L.Q., D.S.R., S.S.K., C.M., S.J.J.)
| | - Jonathan Duffy
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia (J.D.)
| | - In-Lu Amy Liu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California (C.Z., I.A.L., L.S.S., W.C., L.Q., D.S.R., S.S.K., C.M., S.J.J.)
| | - Lina S Sy
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California (C.Z., I.A.L., L.S.S., W.C., L.Q., D.S.R., S.S.K., C.M., S.J.J.)
| | - Wansu Chen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California (C.Z., I.A.L., L.S.S., W.C., L.Q., D.S.R., S.S.K., C.M., S.J.J.)
| | - Lei Qian
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California (C.Z., I.A.L., L.S.S., W.C., L.Q., D.S.R., S.S.K., C.M., S.J.J.)
| | - Ronald A Navarro
- Kaiser Permanente South Bay Medical Center, Harbor City, California (R.A.N.)
| | - Denison S Ryan
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California (C.Z., I.A.L., L.S.S., W.C., L.Q., D.S.R., S.S.K., C.M., S.J.J.)
| | - Sunhea S Kim
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California (C.Z., I.A.L., L.S.S., W.C., L.Q., D.S.R., S.S.K., C.M., S.J.J.)
| | - Cheryl Mercado
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California (C.Z., I.A.L., L.S.S., W.C., L.Q., D.S.R., S.S.K., C.M., S.J.J.)
| | - Steven J Jacobsen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California (C.Z., I.A.L., L.S.S., W.C., L.Q., D.S.R., S.S.K., C.M., S.J.J.)
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19
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Abstract
This study assesses hip fracture surgery volumes among older individuals in California during the pandemic compared with prepandemic rates.
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Affiliation(s)
- Kanu Okike
- Hawaii Permanente Medical Group, Kaiser Permanente, Honolulu, Hawaiʻi
| | - Priscilla H. Chan
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Ronald A. Navarro
- Southern California Permanente Medical Group, Kaiser Permanente, Pasadena, California
| | - Monti X. Khatod
- Southern California Permanente Medical Group, Kaiser Permanente, Pasadena, California
| | - Elizabeth W. Paxton
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Heather A. Prentice
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
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20
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Farley KX, Dawes AM, Wilson JM, Toston RJ, Hurt JT, Gottschalk MB, Navarro RA, Wagner ER. Racial Disparities in the Utilization of Shoulder Arthroplasty in the United States. JB JS Open Access 2022; 7:JBJSOA-D-21-00144. [PMID: 35673617 PMCID: PMC9165742 DOI: 10.2106/jbjs.oa.21.00144] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
As the incidence of shoulder arthroplasty rises at exponential rates, race is an important consideration, as racial disparities have been reported in lower-extremity arthroplasty in the United States. Our study sought to examine these disparities.
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Affiliation(s)
- Kevin X. Farley
- Department of Orthopaedic Surgery, Oakland University William Beaumont Orthopaedics, Royal Oaks, Michigan
| | - Alexander M. Dawes
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Jacob M. Wilson
- Division of Adult Reconstruction, Department of Orthopedic Surgery, Mayo Clinic Rochester, Rochester, Minnesota
| | - Roy J. Toston
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - John T. Hurt
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Michael B. Gottschalk
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Ronald A. Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente, Pasadena, California
| | - Eric R. Wagner
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
- Email for corresponding author:
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21
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Reddy NC, Prentice HA, Paxton EW, Hinman AD, Lin AG, Navarro RA. Association Between Same-Day Discharge Total Joint Arthroplasty and Risk of 90-Day Adverse Events in Patients with ASA Classification of ≥3. J Bone Joint Surg Am 2021; 103:2032-2044. [PMID: 34495903 DOI: 10.2106/jbjs.20.02110] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although safety in same-day discharge total joint arthroplasty (TJA) has been reported, findings are limited to healthier patients, specific surgeons, and/or specific institutions. Indications for same-day discharge TJA have expanded to include patients with multiple comorbidities; however, safety in this specific patient population remains unknown. Therefore, we sought to compare the risk of 90-day adverse events in higher-risk patients undergoing same-day discharge versus inpatient TJA. METHODS The Kaiser Permanente Total Joint Replacement Registry was utilized to conduct a cohort study. All patients with an American Society of Anesthesiologists (ASA) classification of ≥3 who underwent primary elective TJA for osteoarthritis from 2017 through 2018 were identified. The risk of 90-day adverse events (i.e., emergency department visits, unplanned readmissions, complications, and mortality) was evaluated with use of propensity score-weighted Cox proportional hazard regression including noninferiority testing with a margin of 1.10. RESULTS The cohort included a total of 5,250 patients who underwent total hip arthroplasty and 9,752 patients who underwent total knee arthroplasty, of whom 1,742 (33.2%) and 3,283 (33.7%) had same-day discharge, respectively. Same-day discharge hip arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (hazard ratio [HR], 0.73; 1-sided HR 95% upper bound [UB], 0.84), readmissions (HR, 0.47; 95% UB, 0.61), and complications (HR, 0.63; 95% UB, 0.75); we did not have evidence of noninferiority for mortality (HR, 0.84; 95% UB, 1.97). Same-day discharge knee arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (HR, 0.79; 95% UB, 0.87), readmission (HR, 0.80; 95% UB, 0.95), complications (HR, 0.72; 95% UB, 0.82), and mortality (HR, 0.53; 95% UB, 1.03). CONCLUSIONS We found that same-day discharge TJA did not increase the risk of emergency department visits, unplanned readmissions, and complications compared with an inpatient stay for higher-risk patients, suggesting that it is possible to expand indications for same-day discharge TJA in the hospital setting while maintaining safety. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nithin C Reddy
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, California
| | - Heather A Prentice
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Adrian D Hinman
- Department of Orthopaedics, The Permanente Medical Group, San Leandro, California
| | - Abraham G Lin
- Department of Orthopaedics, Southern California Permanente Medical Group, Irvine, California
| | - Ronald A Navarro
- Department of Orthopaedics, Southern California Permanente Medical Group, Harbor City, California
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22
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Wang MC, Chan PH, Paxton EW, Bellows J, Koplan K, Rabrenovich V, Convissar J, Reddy NC, Grimsrud CD, Navarro RA. Factors Influencing Patient Satisfaction With Care and Surgical Outcomes for Total Hip and Knee Replacement. Perm J 2021; 25:21.043. [PMID: 35348097 PMCID: PMC8784075 DOI: 10.7812/tpp/21.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Although patient satisfaction with total joint arthroplasty has been a well-measured outcome, little is known about how preadmission and post-discharge care experiences affect patients' rating of satisfaction. OBJECTIVE This work aimed to identify actionable factors associated with better ratings of overall care and surgical results. METHODS A 36-item survey assessing care in the preoperative, perioperative, and post-discharge phases of care and across all phases was mailed to 7,031 patients who underwent primary unilateral elective total hip arthroplasty and total knee arthroplasty in 2018. Exploratory factor analysis identified 7 actionable domains. Stepwise logistic regression models identified domains associated with ratings of overall care and satisfaction with surgical outcome. RESULTS Of the 3,026 (43%) patients who returned the survey; 2,814 (93%) rated their overall experience of care as very good or excellent and satisfaction with surgical results as ≥ 7 on a 10-point scale. In exploratory factor analysis, four factors predicted higher ratings of both overall care and surgical outcome: knowing what to do with symptoms and pain during recovery (factor 1), self-reported health (factor 3), knowing what to expect before surgery (factor 4), and shared decision making (factor 6). Coordinated information among providers (factor 2), home health experience (factor 5), and patient-provider relationships (factor 7) also predicted overall care ratings. CONCLUSION Patient-centered quality improvement in total joint replacement care requires thinking of care across the entire episode, including before and after the hospital stay for surgery, in addition to perioperative care. The actionable factors identified from this study can be incorporated into total joint replacement care to improve patients' satisfaction with overall care and surgical results.
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Affiliation(s)
- Margaret C Wang
- Care Management Institute, Kaiser Permanente, Oakland, CA
- Now with Stanford Health Care, Stanford, CA
| | - Priscilla H Chan
- Surgical Outcomes and Analysis Department, Southern California Permanente Medical Group, San Diego, CA
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis Department, Southern California Permanente Medical Group, San Diego, CA
| | - Jim Bellows
- Care Management Institute, Kaiser Permanente, Oakland, CA
| | - Kate Koplan
- The Southeast Permanente Medical Group, Atlanta, GA
| | | | | | - Nithin C Reddy
- Southern California Permanente Medical Group, San Diego, CA
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Crain NA, Goharderakhshan RZ, Reddy NC, Apfel AM, Navarro RA. The Role of Intraoperative Urinary Catheters on Postoperative Urinary Retention after Total Joint Arthroplasty: A Multi-Hospital Retrospective Study on 9,580 Patients. Arch Bone Jt Surg 2021; 9:480-486. [PMID: 34692929 DOI: 10.22038/abjs.2020.49205.2441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 12/02/2020] [Indexed: 12/27/2022]
Abstract
Background Urinary catheters (UC) are used by some surgeons during total joint arthroplasty (TJA). This study investigated the impact of intraoperative urinary catheters on postoperative urinary retention (POUR) following TJA cases. Methods We conducted a retrospective comparative study across 11 medical centers on 9,580 TJA patients. Visits to urgent care or the emergency department within 7 and 30 postoperative days were reviewed. Medical records over a 12-month period for all patients older than 18 years old were used to gather demographic and surgical data as well as the incidence of urinary tract infection (UTI). Chi-squared tests (RStudio) were used to determine statistical significance against P-Values (P) < 0.05. Results 13 (0.14%) patients returned within 7 days for POUR. POUR was more common in males [10 (0.3%) vs. 3 (0.1%) females, (P = 0.01)]. There was no difference in POUR when comparing total hip and knee arthroplasty procedures [0.16% vs. 0.12%, (P = 0.60)]. Of all operations, 25% had intraoperative UC use. There was no difference in POUR between the UC and no UC groups [0.21 vs. 0.11%, (P = 0.26)]. However, there was an increase in UTI in UC vs. no UC use within 7 postoperative days [0.92 vs. 0.43%, (P = 0.005)] and 30 postoperative days [2.60 vs. 1.50 %, (P < 0.001)]. Conclusion In our study, there was no difference in POUR rates between the intraoperative UC vs. no UC groups. Therefore, the use of intraoperative UC may not decrease the rate of POUR following TJA procedures. Additionally, UTI risk was higher in the UC group which may be attributable to other factors, especially when comparing female vs. male patients.
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Affiliation(s)
- Nikhil A Crain
- Department of Orthopedics, South Bay Medical Center, Kaiser Permanente Southern California Medical Group, Harbor City, CA, USA.,2196 Gaston Street, Winston-Salem, NC, USA
| | - Reza Z Goharderakhshan
- Department of Urology, South Bay Medical Center, Kaiser Permanente Southern California Medical Group, Harbor City, CA, USA
| | - Nithin C Reddy
- Department of Orthopedics, San Diego Medical Center, Kaiser Permanente Southern California Medical Group, San Diego, CA, USA
| | - Allison M Apfel
- Department of Orthopedics, South Bay Medical Center, Kaiser Permanente Southern California Medical Group, Harbor City, CA, USA
| | - Ronald A Navarro
- Department of Orthopedics, South Bay Medical Center, Kaiser Permanente Southern California Medical Group, Harbor City, CA, USA
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24
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Bohm ER, Kirby S, Trepman E, Hallstrom BR, Rolfson O, Wilkinson JM, Sayers A, Overgaard S, Lyman S, Franklin PD, Dunn J, Denissen G, W-Dahl A, Ingelsrud LH, Navarro RA. Collection and Reporting of Patient-reported Outcome Measures in Arthroplasty Registries: Multinational Survey and Recommendations. Clin Orthop Relat Res 2021; 479:2151-2166. [PMID: 34288899 PMCID: PMC8445553 DOI: 10.1097/corr.0000000000001852] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/12/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are validated questionnaires that are completed by patients. Arthroplasty registries vary in PROM collection and use. Current information about registry collection and use of PROMs is important to help improve methods of PROM data analysis, reporting, comparison, and use toward improving clinical practice. QUESTIONS/PURPOSES To characterize PROM collection and use by registries, we asked: (1) What is the current practice of PROM collection by arthroplasty registries that are current or former members of the International Society of Arthroplasty Registries, and are there sufficient similarities in PROM collection between registries to enable useful international comparisons that could inform the improvement of arthroplasty care? (2) How do registries differ in PROM administration and demographic, clinical, and comorbidity index variables collected for case-mix adjustment in data analysis and reporting? (3) What quality assurance methods are used for PROMs, and how are PROM results reported and used by registries? (4) What recommendations to arthroplasty registries may improve PROM reporting and facilitate international comparisons? METHODS An electronic survey was developed with questions about registry structure and collection, analysis, reporting, and use of PROM data and distributed to directors or senior administrators of 39 arthroplasty registries that were current or former members of the International Society of Arthroplasty Registries. In all, 64% (25 of 39) of registries responded and completed the survey. Missing responses from incomplete surveys were captured by contacting the registries, and up to three reminder emails were sent to nonresponding registries. Recommendations about PROM collection were drafted, revised, and approved by the International Society of Arthroplasty Registries PROMs Working Group members. RESULTS Of the 25 registries that completed the survey, 15 collected generic PROMs, most frequently the EuroQol-5 Dimension survey; 16 collected joint-specific PROMs, most frequently the Knee Injury and Osteoarthritis Outcome Score and Hip Disability and Osteoarthritis Outcome Score; and 11 registries collected a satisfaction item. Most registries administered PROM questionnaires within 3 months before and 1 year after surgery. All 16 registries that collected PROM data collected patient age, sex or gender, BMI, indication for the primary arthroplasty, reason for revision arthroplasty, and a comorbidity index, most often the American Society of Anesthesiologists classification. All 16 registries performed regular auditing and reporting of data quality, and most registries reported PROM results to hospitals and linked PROM data to other data sets such as hospital, medication, billing, and emergency care databases. Recommendations for transparent reporting of PROMs were grouped into four categories: demographic and clinical, survey administration, data analysis, and results. CONCLUSION Although registries differed in PROM collection and use, there were sufficient similarities that may enable useful data comparisons. The International Society of Arthroplasty Registries PROMs Working Group recommendations identify issues that may be important to most registries such as the need to make decisions about survey times and collection methods, as well as how to select generic and joint-specific surveys, handle missing data and attrition, report data, and ensure representativeness of the sample. CLINICAL RELEVANCE By collecting PROMs, registries can provide patient-centered data to surgeons, hospitals, and national entities to improve arthroplasty care.
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Affiliation(s)
- Eric R. Bohm
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sarah Kirby
- George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Elly Trepman
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
- University of South Alabama College of Medicine, Mobile, AL, USA
| | - Brian R. Hallstrom
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ola Rolfson
- Department of Orthopaedics at Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - J. Mark Wilkinson
- Department of Oncology and Metabolism, University of Sheffield, The Medical School, Sheffield, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, Learning and Research, University of Bristol, Southmead Hospital, Bristol, UK
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of South Denmark, Odense, Denmark
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stephen Lyman
- Hospital for Special Surgery, New York, NY, USA
- Kyushu University School of Medicine, Fukuoka, Japan
| | - Patricia D. Franklin
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer Dunn
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Geke Denissen
- Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Implantaten), 's-Hertogenbosch, the Netherlands
| | - Annette W-Dahl
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Lina Holm Ingelsrud
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Ronald A. Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente South Bay Medical Center, Harbor City, CA, USA
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Nau C, Bruxvoort K, Navarro RA, Chevez SG, Hogan TA, Ironside KR, Ludwig SM, Ngo-Metzger Q, Mourra NR, Young DR, Sangha N, Turner BP, Li IX, Padilla A, Chen A, Hong V, Yau V, Tartof S. COVID-19 Inequities Across Multiple Racial and Ethnic Groups: Results From an Integrated Health Care Organization. Ann Intern Med 2021; 174:1183-1186. [PMID: 33872046 PMCID: PMC8082524 DOI: 10.7326/m20-8283] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Claudia Nau
- Kaiser Permanente Southern California, Pasadena, California
| | | | - Ronald A Navarro
- South Bay Medical Center, Kaiser Permanente Southern California, Harbor City, California
| | - Shari G Chevez
- Kaiser Permanente Southern California, Pasadena, California
| | - Tiffany A Hogan
- Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, California
| | - Kristen R Ironside
- Los Angeles Medical Center, Kaiser Permanente Southern California, Pasadena, California
| | - Stacey M Ludwig
- Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, California
| | | | - Natalie R Mourra
- Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, California
| | | | - Navdeep Sangha
- Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, California
| | - Branden P Turner
- West Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, California
| | - Iona Xia Li
- Kaiser Permanente Southern California, Pasadena, California
| | | | - Aiyu Chen
- Kaiser Permanente Southern California, Pasadena, California
| | - Vennis Hong
- Kaiser Permanente Southern California, Pasadena, California
| | | | - Sara Tartof
- Kaiser Permanente Southern California, Pasadena, California
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26
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Zeltser DW, Prentice HA, Navarro RA, Mirzayan R, Dillon MT, Foroohar A. Total Elbow Arthroplasty: A Descriptive Analysis of 170 Patients From a United States Integrated Health Care System. J Hand Surg Am 2021; 46:552-559. [PMID: 33896647 DOI: 10.1016/j.jhsa.2021.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 01/11/2021] [Accepted: 03/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Total elbow arthroplasty (TEA) can be used, with varying degrees of success, for the treatment of rheumatoid arthritis, osteoarthritis, and distal humerus fractures and their sequelae in elderly patients. Some of the largest studies of TEA have included data from more than 20 years ago and may not reflect the current practice of TEA. We sought to describe a modern cohort of patients who underwent TEA in a United States integrated health care system. METHODS All patients aged 18 years and older who underwent primary unilateral TEA from January 1, 2009, through March 31, 2018, were identified to conduct a descriptive study. The patients' characteristics and demographics, including age, body mass index, sex, diabetes status, American Society of Anesthesiologists classification, and surgical indication, were recorded. The crude cumulative revision probability as well as the 90-day postoperative incidence rate of emergency department visit, readmission, and mortality was calculated. RESULTS A total of 170 patients met our inclusion criteria. The annual procedure volume nearly doubled, from 11 procedures in 2009 to 21 procedures in 2017. The most common indication for TEA was fracture (40.6%), followed by rheumatoid arthritis (36.5%). At 4-year follow up, the crude cumulative revision probability was 9.8% (95% confidence interval, 5.6%-16.9%). Of the 170 patients who underwent TEA, 43 (25.3%) experienced a 90-day emergency department visit, 24 (14.1%) experienced a 90-day readmission, and 2 (1.2%) died within 90 days postoperatively. CONCLUSIONS This cohort of patients who underwent TEA using modern implants showed a notable increase in the volume of TEA over the study period, with more TEAs performed for trauma. The incidence of readmission and emergency department visits following TEA were high in this study. Further studies are needed to better define the current practice of TEA in the community at large. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- David W Zeltser
- Department of Orthopedic Surgery, The Permanente Medical Group, South San Francisco, CA.
| | | | - Ronald A Navarro
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Harbor City, CA
| | - Raffy Mirzayan
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Baldwin Park, CA
| | - Mark T Dillon
- Department of Orthopedic Surgery, The Permanente Medical Group, Sacramento, CA
| | - Abtin Foroohar
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Harbor City, CA
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27
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Zheng C, Duffy J, Liu ILA, Sy LS, Navarro RA, Kim SS, Ryan DS, Chen W, Qian L, Mercado C, Jacobsen SJ. Identifying Cases of Shoulder Injury Related to Vaccine Administration (SIRVA) in the United States: Development and Validation of a Natural Language Processing Method (Preprint). JMIR Public Health Surveill 2021; 8:e30426. [PMID: 35608886 PMCID: PMC9175103 DOI: 10.2196/30426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 02/22/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Shoulder injury related to vaccine administration (SIRVA) accounts for more than half of all claims received by the National Vaccine Injury Compensation Program. However, due to the difficulty of finding SIRVA cases in large health care databases, population-based studies are scarce. Objective The goal of the research was to develop a natural language processing (NLP) method to identify SIRVA cases from clinical notes. Methods We conducted the study among members of a large integrated health care organization who were vaccinated between April 1, 2016, and December 31, 2017, and had subsequent diagnosis codes indicative of shoulder injury. Based on a training data set with a chart review reference standard of 164 cases, we developed an NLP algorithm to extract shoulder disorder information, including prior vaccination, anatomic location, temporality and causality. The algorithm identified 3 groups of positive SIRVA cases (definite, probable, and possible) based on the strength of evidence. We compared NLP results to a chart review reference standard of 100 vaccinated cases. We then applied the final automated NLP algorithm to a broader cohort of vaccinated persons with a shoulder injury diagnosis code and performed manual chart confirmation on a random sample of NLP-identified definite cases and all NLP-identified probable and possible cases. Results In the validation sample, the NLP algorithm had 100% accuracy for identifying 4 SIRVA cases and 96 cases without SIRVA. In the broader cohort of 53,585 vaccinations, the NLP algorithm identified 291 definite, 124 probable, and 52 possible SIRVA cases. The chart-confirmation rates for these groups were 95.5% (278/291), 67.7% (84/124), and 17.3% (9/52), respectively. Conclusions The algorithm performed with high sensitivity and reasonable specificity in identifying positive SIRVA cases. The NLP algorithm can potentially be used in future population-based studies to identify this rare adverse event, avoiding labor-intensive chart review validation.
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Affiliation(s)
- Chengyi Zheng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Jonathan Duffy
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Ronald A Navarro
- Kaiser Permanente South Bay Medical Center, Harbor City, CA, United States
| | - Sunhea S Kim
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Denison S Ryan
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Wansu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Cheryl Mercado
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
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Navarro RA. Long-Term Value May Determine if RTSA for Cuff-Intact Osteoarthritis with Glenoid Defects Does Not Require Bone Grafts or Augments: Commentary on an article by Edward G. McFarland, MD, et al.: "Reverse Total Shoulder Arthroplasty without Bone-Grafting for Severe Glenoid Bone Loss in Patients with Osteoarthritis and Intact Rotator Cuff. A Concise 5-Year Follow-up of a Previous Report". J Bone Joint Surg Am 2021; 103:e30. [PMID: 33787559 DOI: 10.2106/jbjs.21.00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Ronald A Navarro
- Southern California Permanente Medical Group, Kaiser Permanente, Pasadena, California.,Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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29
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Dillon MT, Chan PH, Prentice HA, Royse KE, Paxton EW, Okike K, Khatod M, Navarro RA. The effect of a statewide COVID-19 shelter-in-place order on shoulder arthroplasty for proximal humerus fracture volume and length of stay. ACTA ACUST UNITED AC 2021; 31:339-345. [PMID: 34334985 PMCID: PMC7923956 DOI: 10.1053/j.sart.2021.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Although the COVID-19 pandemic has disrupted elective shoulder arthroplasty throughput, traumatic shoulder arthroplasty procedures are less apt to be postponed. We sought to evaluate shoulder arthroplasty utilization for fracture during the COVID-19 pandemic and California's associated shelter-in-place order compared to historical controls. Methods We conducted a cohort study with historical controls, identifying patients who underwent shoulder arthroplasty for proximal humerus fracture in California using our integrated electronic health record. The time period of interest was following the implementation of the statewide shelter-in-place order: March 19, 2020-May 31, 2020. This was compared to three historical periods: January 1, 2020-March 18, 2020, March 18, 2019-May 31, 2019, and January 1, 2019-March 18, 2019. Procedure volume, patient characteristics, in-hospital length of stay, and 30-day events (emergency department visit, readmission, infection, pneumonia, and death) were reported. Changes over time were analyzed using linear regression adjusted for usual seasonal and yearly changes and age, sex, comorbidities, and postadmission factors. Results Surgical volume dropped from an average of 4.4, 5.2, and 2.6 surgeries per week in the historical time periods, respectively, to 2.4 surgeries per week after shelter-in-place. While no more than 30% of all shoulder arthroplasty procedures performed during any given week were for fracture during the historical time periods, arthroplasties performed for fracture was the overwhelming primary indication immediately after the shelter-in-place order. More patients were discharged the day of surgery (+33.2%, P = .019) after the shelter-in-place order, but we did not observe a change in any of the corresponding 30-day events. Conclusions The volume of shoulder arthroplasty for fracture dropped during the time of COVID-19. The reduction in volume could be due to less shoulder trauma due to shelter-in-place or a change in the indications for arthroplasty given the perceived higher risks associated with intubation and surgical care. We noted more patients undergoing shoulder arthroplasty for fracture were safely discharged on the day of surgery, suggesting this may be a safe practice that can be adopted moving forward. Level of Evidence Level III; Retrospective Case-control Comparative Study
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Affiliation(s)
- Mark T Dillon
- Department of Orthopedic Surgery, The Permanente Medical Group, Sacramento, CA, USA
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | | | - Kathryn E Royse
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | | | - Kanu Okike
- Department of Orthopedic Surgery, Hawaii Permanente Medical Group, Honolulu, HI, USA
| | - Monti Khatod
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, West Los Angeles, CA, USA
| | - Ronald A Navarro
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, South Bay, CA, USA
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Dillon MT, Page RS, Graves SE, Lorimer MF, Prentice HA, Harris JE, Paxton EW, Navarro RA. Early revision in anatomic total shoulder arthroplasty in osteoarthritis: a cross-registry comparison. Shoulder Elbow 2020; 12:81-87. [PMID: 33343719 PMCID: PMC7726180 DOI: 10.1177/1758573219842168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/11/2019] [Accepted: 03/13/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND We evaluated anatomic total shoulders undergoing early revision (less than two years) in the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Kaiser Permanente Shoulder Arthroplasty Registry (KPSAR). METHODS A cross-sectional comparison of both registries was performed between the years of 2009 and 2012. Only patients who underwent anatomic total shoulder arthroplasty for a primary diagnosis of osteoarthritis were included. Aggregate-level data of patients undergoing early revisions done within two years of index arthroplasty were evaluated, and descriptive analysis was conducted. RESULTS During the study period, 4614 patients were identified in the AOANJRR compared to 2036 in the KPSAR. Rotator cuff pathology, component loosening, and prosthetic instability were among the most common reasons for revision in both registries. A higher rate of revision in the AOANJRR was found to be secondary to the failure of one specific prosthesis, which has since been discontinued. DISCUSSION Comparing reasons for early revision in total shoulder arthroplasty revealed several similarities between the AOANJRR and KPSAR. Differences were also noted, and this study served to highlight the importance prosthesis selection can play in determining outcomes. Cooperation among registries may allow for earlier identification of risk factors for failure in shoulder arthroplasty.
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Affiliation(s)
- Mark T Dillon
- Department of Orthopedic Surgery, The Permanente Medical Group, Sacramento, CA, USA,Mark T Dillon, Department of Orthopedic Surgery, The Permanente Medical Group, 2025 Morse Avenue, Sacramento, CA 95825, USA.
| | - Richard S Page
- Deakin University School of Medicine, St. John of God Hospital, University Hospital Geelong, Geelong, Victoria, Australia
| | - Stephen E Graves
- Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, North Terrace Adelaide, South Australia, Australia
| | - Michelle F Lorimer
- South Australian Health and Medical Research Institute, North Terrace Adelaide, South Australia, Australia
| | | | - Jessica E Harris
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | | | - Ronald A Navarro
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Harbor City, CA, USA
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Dillon MT, Chan PH, Prentice HA, Burfeind WE, Yian EH, Singh A, Paxton EW, Navarro RA. The association between glenoid component design and revision risk in anatomic total shoulder arthroplasty. J Shoulder Elbow Surg 2020; 29:2089-2096. [PMID: 32507730 DOI: 10.1016/j.jse.2020.02.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/10/2020] [Accepted: 02/20/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Anatomic total shoulder arthroplasty (TSA) is a proven treatment for glenohumeral joint osteoarthritis, with superior results compared with hemiarthroplasty. However, glenoid component loosening remains a problem and is one of the most common causes of failure in TSA. Multiple component designs have been developed in an attempt to reduce loosening rates. The purpose of this study was to evaluate risk of revision after anatomic TSA according to the glenoid component design. METHODS We conducted a cohort study including patients aged ≥18 years who underwent primary elective TSA for the diagnosis of osteoarthritis between 2010 and 2017. Patients with missing implant information, who received stemless humeral implants, or who received augmented glenoid implants, were excluded. Glenoid component designs used were categorized into 4 mutually exclusive treatment groups: polyethylene central-pegged ingrowth, polyethylene-metal hybrid, polyethylene all-cemented pegged, and polyethylene cemented keeled. Multivariable competing risk regression was used to evaluate the risk of glenoid loosening as a cause-specific revision by the glenoid component design. RESULTS Of the 5566 TSA included in the final cohort, 39.2% of glenoid implants were polyethylene central-pegged ingrowth, 31.1% were polyethylene-metal hybrid, 26.0% were polyethylene all-cemented pegged, and 3.6% were polyethylene cemented keeled. At 6-year final follow-up, 4.1% of TSA were revised for any cause, and 1.4% for glenoid loosening. Compared with the polyethylene central-pegged ingrowth design, no difference in glenoid loosening revision risk was observed for the polyethylene-metal hybrid design (hazard ratio [HR] = 1.15, 95% confidence interval [CI] = 0.42-3.20). However, both the polyethylene all-cemented pegged (HR = 2.48, 95% CI = 1.08-5.66) and polyethylene cemented keeled (HR = 3.84, 95% CI = 1.13-13.00) designs had higher risks for revision due to glenoid loosening. CONCLUSIONS We observed glenoid component designs to be associated with differential risks in revision due to glenoid loosening with polyethylene all-cemented pegged glenoids and polyethylene cemented keeled glenoids having higher risks when compared with polyethylene central-pegged ingrowth glenoids. Surgeons may want to consider the glenoid component design when performing anatomic TSA.
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Affiliation(s)
- Mark T Dillon
- Department of Orthopaedics, The Permanente Medical Group, Sacramento, CA, USA.
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | | | | | - Edward H Yian
- Department of Orthopaedics, Southern California Permanente Medical Group, Anaheim, CA, USA
| | - Anshuman Singh
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, CA, USA
| | | | - Ronald A Navarro
- Department of Orthopaedics, Southern California Permanente Medical Group, Harbor City, CA, USA
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Navarro RA, Adams AL, Lin CC, Fleming J, Garcia IA, Lee J, Black MH. Does Knee Arthroscopy for Treatment of Meniscal Damage with Osteoarthritis Delay Knee Replacement Compared to Physical Therapy Alone? Clin Orthop Surg 2020; 12:304-311. [PMID: 32904116 PMCID: PMC7449858 DOI: 10.4055/cios19114] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/25/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUD To determine patient factors that lead to treatment of meniscal tears with osteoarthritis (OA) with knee arthroscopy (KA) or physical therapy only (PT-only); and to assess differences in clinical outcomes including the time to knee arthroplasty. METHODS Patients aged ≥ 45 years with OA at meniscal tear diagnosis were followed up from the date of surgery (KA) or first PT visit (PT-only) until partial/total knee replacement surgery, death, disenrollment, or end of study. Demographic and clinical characteristics were compared and used to derive propensity scores. A Cox proportional hazards model was used to estimate the risk of knee replacement surgery and greater healthcare utilization associated with KA vs. PT-only. RESULTS Among 7,026 patients (KA, 69%; PT-only, 31%), 27% had partial or total knee replacement surgery during follow-up. PT-only patients were older and more likely to be women and had more comorbidities. After accounting for differences between groups, the cumulative incidence of knee replacement was modestly but significantly higher for those who received KA than those who underwent PT-only (hazard ratio, 1.30; 95% confidence interval, 1.17-1.44; p < 0.001), although there was no significant difference in health service utilization, narcotic medication dispenses, or knee injections after initiating treatment. CONCLUSIONS For patients with meniscal damage complicated by OA, those who underwent KA were 30% more likely to have partial or total knee replacement surgery at any given time than those who had PT alone.
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Affiliation(s)
- Ronald A. Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente South Bay Medical Center, Harbor City, CA, USA
| | - Annette L. Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Charles C. Lin
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - John Fleming
- Torrance Orthopaedic and Sports Medicine Group, Torrance, CA, USA
| | - Ivan A. Garcia
- Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, CA, USA
| | - Janet Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Mary Helen Black
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Hesse EM, Navarro RA, Daley MF, Getahun D, Henninger ML, Jackson LA, Nordin J, Olson SC, Zerbo O, Zheng C, Duffy J. Risk for Subdeltoid Bursitis After Influenza Vaccination: A Population-Based Cohort Study. Ann Intern Med 2020; 173:253-261. [PMID: 32568572 DOI: 10.7326/m19-3176] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Subdeltoid bursitis has been reported as an adverse event after intramuscular vaccination in the deltoid muscle. Most published case reports involved influenza vaccine. OBJECTIVE To estimate the risk for subdeltoid bursitis after influenza vaccination. DESIGN Retrospective cohort study. SETTING The Vaccine Safety Datalink, which contains health encounter data for 10.2 million members of 7 U.S. health care organizations. PATIENTS Persons who received an inactivated influenza vaccine during the 2016-2017 influenza season. MEASUREMENTS Potential incident cases were identified by searching administrative data for persons with a shoulder bursitis diagnostic code within 180 days after receiving an injectable influenza vaccine in the same arm. The date of reported bursitis symptom onset was abstracted from the medical record. A self-controlled risk interval analysis was used to calculate the incidence rate ratio of bursitis in a risk interval of 0 to 2 days after vaccination versus a control interval of 30 to 60 days, which represents the background rate. The attributable risk was also estimated. RESULTS The cohort included 2 943 493 vaccinated persons. Sixteen cases of symptom onset in the risk interval and 51 cases of symptom onset in the control interval were identified. The median age of persons in the risk interval was 57.5 years (range, 24 to 98 years), and 69% were women. The incidence rate ratio was 3.24 (95% CI, 1.85 to 5.68). The attributable risk was 7.78 (CI, 2.19 to 13.38) additional cases of bursitis per 1 million persons vaccinated. LIMITATION The results may not be generalizable to vaccinations done in other types of health care settings. CONCLUSION Although an increased risk for bursitis after vaccination was present, the absolute risk was small. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.
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Affiliation(s)
- Elisabeth M Hesse
- Epidemic Intelligence Service and Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia (E.M.H., J.D.)
| | - Ronald A Navarro
- Kaiser Permanente South Bay Medical Center, Harbor City, California (R.A.N.)
| | - Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (M.F.D.)
| | | | | | - Lisa A Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (L.A.J.)
| | - James Nordin
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota (J.N.)
| | - Scott C Olson
- Marshfield Clinic Research Institute, Center for Clinical Epidemiology and Population Health, Marshfield, Wisconsin (S.C.O.)
| | - Ousseny Zerbo
- Kaiser Permanente Vaccine Study Center, Oakland, California (O.Z.)
| | - Chengyi Zheng
- Kaiser Permanente, Pasadena, California (D.G., C.Z.)
| | - Jonathan Duffy
- Epidemic Intelligence Service and Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia (E.M.H., J.D.)
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Navarro RA, Reddy NC, Weiss JM, Yates AJ, Fu FH, McKee M, Lederman ES. Orthopaedic Systems Response to and Return from the COVID-19 Pandemic: Lessons for Future Crisis Management. J Bone Joint Surg Am 2020; 102:e75. [PMID: 32675663 PMCID: PMC7396222 DOI: 10.2106/jbjs.20.00709] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has become the dominant health-care issue of this generation and has reached every corner of the health-care delivery spectrum. Our 3 orthopaedic departments enacted a response to the COVID-19 pandemic within our organizations. We discuss our health-care systems' response to the outbreak and offer discussion for the recovery of the orthopaedic service line within large health-care systems.
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Affiliation(s)
| | - Nithin C. Reddy
- Kaiser Permanente Southern California, San Diego, California
| | | | - Adolph J. Yates
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Freddie H. Fu
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael McKee
- University of Arizona College of Medicine–Phoenix, Phoenix, Arizona
- Banner Health, Phoenix Arizona
| | - Evan S. Lederman
- University of Arizona College of Medicine–Phoenix, Phoenix, Arizona
- Banner Health, Phoenix Arizona
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Meredith SJ, Rauer T, Chmielewski TL, Fink C, Diermeier T, Rothrauff BB, Svantesson E, Hamrin Senorski E, Hewett TE, Sherman SL, Lesniak BP, Bizzini M, Chen S, Cohen M, Villa SD, Engebretsen L, Feng H, Ferretti M, Fu FH, Imhoff AB, Kaeding CC, Karlsson J, Kuroda R, Lynch AD, Menetrey J, Musahl V, Navarro RA, Rabuck SJ, Siebold R, Snyder-Mackler L, Spalding T, van Eck C, Vyas D, Webster K, Wilk K. Return to Sport After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Return to Sport Consensus Group. Orthop J Sports Med 2020; 8:2325967120930829. [PMID: 32647735 PMCID: PMC7328222 DOI: 10.1177/2325967120930829] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/20/2020] [Indexed: 12/28/2022] Open
Abstract
Background A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level. Purpose The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making. Study Design Consensus statement. Methods An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. Results Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries. Conclusion The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery.
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Affiliation(s)
- Sean J Meredith
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Thomas Rauer
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Terese L Chmielewski
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christian Fink
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Theresa Diermeier
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin B Rothrauff
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eleonor Svantesson
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric Hamrin Senorski
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Timothy E Hewett
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Seth L Sherman
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bryson P Lesniak
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Mario Bizzini
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shiyi Chen
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Moises Cohen
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stefano Della Villa
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lars Engebretsen
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hua Feng
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mario Ferretti
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andreas B Imhoff
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christopher C Kaeding
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jon Karlsson
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ryosuke Kuroda
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew D Lynch
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jacques Menetrey
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ronald A Navarro
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stephen J Rabuck
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rainer Siebold
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lynn Snyder-Mackler
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tim Spalding
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carola van Eck
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dharmesh Vyas
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kate Webster
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kevin Wilk
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Hinman AD, Chan PH, Prentice HA, Paxton EW, Okike KM, Navarro RA. The Association of Race/Ethnicity and Total Knee Arthroplasty Outcomes in a Universally Insured Population. J Arthroplasty 2020; 35:1474-1479. [PMID: 32146110 DOI: 10.1016/j.arth.2020.02.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Prior studies have documented racial/ethnic disparities in the United States for total knee arthroplasty (TKA) outcomes. One factor cited as a potential mediator is unequal access to care. We sought to assess whether racial/ethnic disparities persist in a universally insured TKA population. METHODS A US integrated health system's total joint replacement registry was used to identify elective primary TKA (2000-2016). Racial/ethnic differences in revision and 90-day postoperative events (readmission, emergency department [ED] visit, infection, venous thromboembolism, and mortality) were analyzed using Cox proportional hazard and logistic regression with adjustment for confounders. RESULTS Of 129,402 TKA, 68.8% were white, 16.2% were Hispanic, 8.4% were black, and 6.6% were Asian. Compared to white patients, Hispanic patients had lower risks of septic revision (hazard ratio [HR] = 0.69, 95% confidence interval [CI] = 0.57-0.83) and infection (odds ratio [OR] = 0.42, 95% CI = 0.30-0.59), but a higher likelihood of ED visit (OR = 1.28, 95% CI = 1.22-1.34). Black patients had higher risks of aseptic revision (HR = 1.61, 95% CI = 1.42-1.83), readmission (OR = 1.13, 95% CI = 1.02-1.24), and ED visit (OR = 1.31, 95% CI = 1.23-1.39). Asian patients had lower risks of aseptic revision (HR = 0.67, 95% CI = 0.54-0.83), septic revision (HR = 0.78, 95% CI = 0.60-0.99), readmission (OR = 0.89, 95% CI = 0.79-1.00), and venous thromboembolism (OR = 0.59, 95% CI = 0.45-0.78). CONCLUSION We observed differences in TKA outcome, even within a universally insured population. While lower risks in some outcomes were observed for Asian and Hispanic patients, the higher risks of aseptic revision and readmission for black patients and ED visit for black and Hispanic patients warrant further research to determine reasons for these findings to mitigate disparities. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Adrian D Hinman
- Department of Orthopaedic Surgery, The Permanente Medical Group, San Leandro, CA
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | | | | | - Kanu M Okike
- Department of Orthopaedic Surgery, Kaiser Moanalua Medical Center, Honolulu, HI
| | - Ronald A Navarro
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, Harbor City, CA
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Kramer JD, Chan PH, Prentice HA, Hatch J, Dillon MT, Navarro RA. Same-day discharge is not inferior to longer length of in-hospital stay for 90-day readmissions following shoulder arthroplasty. J Shoulder Elbow Surg 2020; 29:898-905. [PMID: 31831281 DOI: 10.1016/j.jse.2019.09.037] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder arthroplasty is a common orthopedic procedure, performed historically in the inpatient setting. However, interest in same-day discharge has increased. We sought to evaluate 90-day readmission, 90-day emergency department (ED) visit, 90-day deep infection, 90-day venous thromboembolism (VTE), and 1-year mortality after same-day shoulder arthroplasty compared with an inpatient stay. METHODS We conducted a retrospective cohort study using data from an integrated health care system's Shoulder Arthroplasty Registry. A total of 6503 elective primary unilateral total shoulder and reverse total shoulder arthroplasties performed between 2005 and 2016 were included; 405 (6%) had same-day discharge. The likelihood of 90-day events, including readmission, ED visit, deep infection, and VTE, and 1-year mortality after same-day discharge was compared with 1- to 4-night inpatient stay using generalized estimating equations with noninferiority testing, adjusting for age, sex, body mass index, race, American Society of Anesthesiologists classification, select comorbidities, osteoarthritis, anesthesia type, procedure type, and surgeon effect. RESULTS We failed to observe a difference between same-day discharge and 1- to 4-night stay in terms of 90-day readmission, 90-day ED visit, and 1-year mortality. Same-day discharge was not inferior to 1- to 4-night stay regarding 90-day readmission, but we did not have evidence to support noninferiority for 90-day ED visits or 1-year mortality. Ninety-day deep infections and VTE were too infrequent for adjusted analysis. CONCLUSIONS We found same-day shoulder arthroplasty not to be inferior to an inpatient stay for 90-day readmission. Future investigation into the reasons for readmission and ED visit after same-day shoulder arthroplasty and interventions to mitigate these adverse events is needed.
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Affiliation(s)
- Jonathan D Kramer
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, San Diego, CA, USA
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | | | - Joshua Hatch
- Department of Orthopaedic Surgery, The Permanente Medical Group, Oakland, CA, USA
| | - Mark T Dillon
- Department of Orthopaedic Surgery, The Permanente Medical Group, Sacramento, CA, USA
| | - Ronald A Navarro
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, Harbor City, CA, USA.
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Prentice HA, Chan PH, Dillon MT, Reddy NC, Navarro RA, Paxton EW. Lower-extremity total joint arthroplasty in shoulder arthroplasty patients: does the order of the lower-extremity total joint arthroplasty matter? J Shoulder Elbow Surg 2020; 29:e45-e51. [PMID: 31521524 DOI: 10.1016/j.jse.2019.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/21/2019] [Accepted: 07/01/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND As total joint arthroplasty (TJA) utilization increases, arthroplasties of multiple joints in a patient are more common. An understanding of the success of shoulder arthroplasty patients also requiring a lower-extremity (hip or knee) TJA is lacking. We evaluated the following questions: (1) Is there a difference in the revision risk following shoulder arthroplasty in patients who also undergo a lower-extremity TJA compared with those who do not? (2) Does the revision risk differ depending on the sequence of the procedures? METHODS Patients who underwent elective primary shoulder arthroplasty from 2009 through 2015 were identified using Kaiser Permanente's shoulder arthroplasty registry. Patients with a lower-extremity TJA were identified using the institution's total joint replacement registry. Revision related to the index shoulder was modeled via Cox regression stratified by procedure type and adjusted for confounders. RESULTS Of the 4751 shoulder arthroplasties identified, 1285 (27.0%) underwent a prior hip and/or knee arthroplasty and 483 (10.2%) underwent a hip and/or knee arthroplasty following the index shoulder arthroplasty. No difference was found in all-cause shoulder revision risk with lower-extremity TJA before (hazard ratio, 1.38; 95% confidence interval, 0.97-1.96) or after (hazard ratio, 1.30; 95% confidence interval, 0.82-2.06) the index shoulder arthroplasty compared with patients who underwent a shoulder arthroplasty only. CONCLUSION In our study sample, we did not observe shoulder revision surgery risk to be different in patients who also underwent a lower-extremity TJA, regardless of the sequence of the 2 procedures. Future prospective studies should investigate whether the timing of the lower-extremity TJA in relation to the shoulder procedure impacts the latter's success.
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Affiliation(s)
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | - Mark T Dillon
- Department of Orthopaedic Surgery, The Permanente Medical Group, Sacramento, CA, USA
| | - Nithin C Reddy
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, San Diego, CA, USA
| | - Ronald A Navarro
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, Harbor City, CA, USA
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Navarro RA, Prentice HA, Inacio MCS, Wyatt R, Maletis GB. The Association Between Race/Ethnicity and Revision Following ACL Reconstruction in a Universally Insured Cohort. J Bone Joint Surg Am 2019; 101:1546-1553. [PMID: 31483397 DOI: 10.2106/jbjs.18.01408] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There have been few large studies involving multiethnic cohorts of patients treated with anterior cruciate ligament reconstruction (ACLR), and therefore, little is known about the role that race/ethnicity may play in the differential risk of undergoing revision surgery following primary ACLR. The purpose of this study was to evaluate whether differences exist by race/ethnicity in the risk of undergoing the elective procedure of aseptic revision in a universally insured cohort of patients who had undergone ACLR. METHODS This was a retrospective cohort study conducted using our integrated health-care system's ACLR registry and including primary ACLRs from 2008 to 2015. Race/ethnicity was categorized into the following 4 groups: non-Hispanic white, black, Hispanic, and Asian. Multivariable Cox proportional-hazard models were used to evaluate the association between race/ethnicity and revision risk while adjusting for age, sex, highest educational attainment, annual household income, graft type, and geographic region in which the ACLR was performed. RESULTS Of the 27,258 included patients,13,567 (49.8%) were white, 7,713 (28.3%) were Hispanic, 3,725 (13.7%) were Asian, and 2,253 (8.3%) were black. Asian patients (hazard ratio [HR] = 0.72; 95% confidence interval [CI] = 0.57 to 0.90) and Hispanic patients (HR = 0.83; 95% CI = 0.70 to 0.98) had a lower risk of undergoing revision surgery than did white patients. Within the first 3.5 years postoperatively, we did not observe a difference in revision risk when black patients were compared with white patients (HR = 0.86; 95% CI = 0.64 to 1.14); after 3.5 years postoperatively, black patients had a lower risk of undergoing revision (HR = 0.23; 95% CI = 0.08 to 0.63). CONCLUSIONS In a large, universally insured ACLR cohort with equal access to care, we observed Asian, Hispanic, and black patients to have a similar or lower risk of undergoing elective revision compared with white patients. These findings emphasize the need for additional investigation into barriers to equal access to care. Because of the sensitivity and complexity of race/ethnicity with surgical outcomes, continued assessment into the reasons for the differences observed, as well as any differences in other clinical outcomes, is warranted. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ronald A Navarro
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, Harbor City, California
| | - Heather A Prentice
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Maria C S Inacio
- Division of Health Sciences, Sansom Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Ronald Wyatt
- Department of Orthopaedic Surgery, The Permanente Medical Group, Walnut Creek, California
| | - Gregory B Maletis
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, Baldwin Park, California
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Singh A, Schultzel M, Fleming JF, Navarro RA. Complications after surgical treatment of distal clavicle fractures. Orthop Traumatol Surg Res 2019; 105:853-859. [PMID: 31202717 DOI: 10.1016/j.otsr.2019.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 01/14/2019] [Accepted: 03/06/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Distal clavicle fractures have low rates of union when treated with conservative measures. Operative treatment is generally recommended for Neer type II and V. Multiple fixation methods exist with no clear gold standard. The goal of the current study is to assess the outcomes and complications of distal clavicle fractures treated with one of three fixation methods: standard clavicular plate, hook plate or suture fixation about the coracoid. METHODS This is a retrospective cohort study of surgically-treated unstable Neer type II and V distal clavicle fractures in adults. These operations were performed by multiple surgeons within a single healthcare system between January 2010 and September 2012. Patients were divided into three cohorts: pre-contoured clavicular locking plates, hook plates, and suture-only fixation methods. Univariate and mulivariate modeling analyses were performed. RESULTS A total of 74 distal clavicle fractures comprised the final cohort. Fifty-eight (77%) of these fractures were Neer type II; the remaining 16 (21.6%) were Neer type V. Median follow-up time was 12 months (range 10-28). BMI, smoking status, diabetes, and ASA class were similar among all cohorts. Twenty-one patients were treated with suture fixation alone (28.3%), 37 with a contoured clavicular plate (50%) and 16 with hook plate fixation (21.6%). Twenty-one patients (28.4%) experienced complications, including two hardware failures requiring revision surgery. A total of 10/16 (62.5%) patients with hook plates required hardware removal for irritation, compared to 6/37 (16.2%) with a contoured clavicular plate (OR=8.61, p value=0.001), and none with sutures alone. A total of 3/21 patients (14.2%) treated with suture fixation methods were diagnosed with adhesive capsulitis post-operatively; no patients in the plate fixation groups received this diagnosis. The Neer V group had a higher proportion of any complications (37.5%) compared to Neer II (25.9%), and a higher rate of stiffness (12.5% v. 1.7% in Neer II). CONCLUSION This study compared the outcomes of three different fixation methods for unstable distal clavicle fractures. The overall union rate with any method of operative intervention was very high (98.6%), consistent with previous studies. Hook plates had a much higher re-operation rate, mostly owing to a higher incidence of hardware removal, an expected outcome owing to the prominence of these plates in the subacromial space. Contoured clavicular plates were associated with a lower incidence of irritation and hardware removal than hook plates, although one patient in this group experienced loss of fracture fixation and went on to asymptomatic radiographic non-union. Suture-only fixation methods had the lowest rate of re-operation, with only one of 21 procedures resulting in failure and requiring revision. However, there was a significantly higher rate of adhesive capsulitis in the suture fixation cohort, perhaps due to the tethering effect of the clavicle to the coracoid or violation of the rotator interval. While this study supports that most distal clavicle fracture fixation methods can achieve stable union, there is a highly variable complication profile associated with each fixation method. The routine use of hook plate fixation cannot be recommended.
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Affiliation(s)
- Anshuman Singh
- Southern California Permanente Medical Group, Pasadena and San Diego, 400 Craven Road, 92078 San Marcos, CA, United States
| | - Mark Schultzel
- Southern California Permanente Medical Group, Pasadena and San Diego, 400 Craven Road, 92078 San Marcos, CA, United States.
| | - John F Fleming
- Coastal Ortho Advanced Orthopaedics, Torrance, CA, United States
| | - Ronald A Navarro
- Southern California Permanente Medical Group, Pasadena and San Diego, 400 Craven Road, 92078 San Marcos, CA, United States
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Okike K, Chan PH, Prentice HA, Navarro RA, Hinman AD, Paxton EW. Association of Race and Ethnicity with Total Hip Arthroplasty Outcomes in a Universally Insured Population. J Bone Joint Surg Am 2019; 101:1160-1167. [PMID: 31274717 DOI: 10.2106/jbjs.18.01316] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prior studies have documented racial and ethnic disparities in total hip arthroplasty (THA) outcomes in the U.S. The purpose of this study was to assess whether racial/ethnic disparities in THA outcomes persist in a universally insured population of patients enrolled in an integrated health-care system. METHODS A U.S. health-care system total joint replacement registry was used to identify patients who underwent elective primary THA between 2001 and 2016. Data on patient demographics, surgical procedures, implant characteristics, and outcomes were obtained from the registry. The outcomes analyzed were lifetime revision (all-cause, aseptic, and septic) and 90-day postoperative events (infection, venous thromboembolism, emergency department [ED] visits, readmission, and mortality). Racial/ethnic differences in outcomes were analyzed with use of multiple regression with adjustment for socioeconomic status and other potential confounders. RESULTS Of 72,755 patients in the study, 79.1% were white, 8.2% were black, 8.5% were Hispanic, and 4.2% were Asian. Compared with white patients, lifetime all-cause revision was lower for black (adjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.66 to 0.94; p = 0.007), Hispanic (adjusted HR, 0.73; 95% CI, 0.61 to 0.87; p = 0.002), and Asian (adjusted HR, 0.49; 95% CI, 0.37 to 0.66; p < 0.001) patients. Ninety-day ED visits were more common among black (adjusted odds ratio [OR], 1.15; 95% CI, 1.05 to 1.25; p = 0.002) and Hispanic patients (adjusted OR, 1.18; 95% CI, 1.08 to 1.28; p < 0.001). For all other postoperative events, minority patients had similar or lower rates compared with white patients. CONCLUSIONS In contrast to prior research, we found that minority patients enrolled in a managed health-care system had rates of lifetime reoperation and 90-day postoperative events that were generally similar to or lower than those of white patients, findings that may be related to the equal access and/or standardized protocols associated with treatment in the managed care system. However, black and Hispanic patients still had higher rates of 90-day ED visits. Further research is required to determine the reasons for this finding and to identify interventions that could reduce unnecessary ED visits. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kanu Okike
- Hawaii Permanente Medical Group, Kaiser Permanente, Honolulu, Hawaii
| | - Priscilla H Chan
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Heather A Prentice
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Ronald A Navarro
- Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, California
| | - Adrian D Hinman
- Northern California Permanente Medical Group, Kaiser Permanente, San Leandro, California
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
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McElvany MD, Chan PH, Prentice HA, Paxton EW, Dillon MT, Navarro RA. Diabetes Disease Severity Was Not Associated with Risk of Deep Infection or Revision After Shoulder Arthroplasty. Clin Orthop Relat Res 2019; 477:1358-1369. [PMID: 31136435 PMCID: PMC6554133 DOI: 10.1097/corr.0000000000000642] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prior studies have identified diabetes and disease severity (defined using hemoglobin A1c [HbA1c]) as potential risk factors for complications after shoulder arthroplasty. Evaluations of diabetes status and risk of adverse outcomes beyond the 30-day window either are limited or have not accounted for disease severity. Further, measures of diabetes severity other than HbA1c have yet to be investigated in a shoulder arthroplasty population. QUESTIONS/PURPOSES (1) Are diabetes status and glycemic control associated with adverse events, including deep infection, all-cause revision, and 90-day readmission after shoulder arthroplasty? (2) Is postoperative HbA1c associated with revision risk? (3) Is there a threshold of preoperative HbA1c that best identifies patients with diabetes who are at higher risk of 3-year deep infection, 1-year all-cause revision, or 90-day readmission? (4) Can the Adapted Diabetes Complications Severity index (aDCSI) be used as an alternative measure of diabetes severity in evaluating the risk of deep infection, all-cause revision, and 90-day readmission and identification of patients with diabetes at higher risk for these events? (5) Is there a difference between elective and traumatic shoulder arthroplasty patients? METHODS We conducted a retrospective registry-based cohort study using Kaiser Permanente's Shoulder Arthroplasty Registry (2005-2015). Primary shoulder arthroplasties were classified as patients with and without diabetes. Patients with diabetes were further evaluated using two disease severity measures (1) HbA1c, with good glycemic control classified as preoperative HbA1c < 7.0% and poor control defined as HbA1c ≥ 7.0%; and (2) aDCSI, classified as mild (score of 0-2) or severe (score ≥ 3) diabetes. Cox regression was used to evaluate the risk of deep infection and revision according to diabetes status and disease severity; conditional logistic regression was used for 90-day readmission. Time-dependent 1-year postoperative HbA1c was used to evaluate revision risk in Cox regression. All models were adjusted for covariates and stratified by elective versus trauma shoulder arthroplasty. Receiver operating characteristic curves were generated for HbA1c and aDCSI to determine whether a threshold exists to identify patients at higher risk of deep infection, all-cause revision, or 90-day readmission. The study sample consisted of 8819 patients; 7353 underwent elective shoulder arthroplasty and 1466 underwent shoulder arthroplasty due to trauma. For elective shoulder arthroplasty, 1430 patients (19%) had diabetes, and among the patients who underwent arthroplasty due to trauma, 444 (30%) had diabetes. RESULTS Patients with diabetes who underwent elective shoulder arthroplasty and had poor glycemic control had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.5; 95% CI, 1.0-2.1; p = 0.032). No association was found for patients with diabetes who underwent shoulder arthroplasty due to trauma. No association was found between postoperative HbA1c and revision risk. Receiver operating characteristic curve analysis suggested preoperative HbA1c performed poorly at differentiating adverse events. When using aDCSI, patients with severe diabetes who underwent both elective and traumatic shoulder arthroplasty had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.6; 95% CI, 1.2-2.2; p = 0.001 and OR, 1.8; 95% CI, 1.2-2.7; p = 0.005, respectively). Similar to HbA1c, the aDCSI was a poor classifier in differentiating adverse events. CONCLUSIONS Of the longer-term outcomes evaluated, more-severe diabetes was only found to be associated with an increase in 90-day readmissions after shoulder arthroplasty; a stronger association was found when using the aDCSI in identifying diabetes severity. Arbitrary cutoffs in HbA1c may not be the best method for determining risk of postoperative outcomes. Future work investigating perioperative diabetes management should work to identify and validate measures, such as the aDCSI, that better identify patients at higher risk for postoperative outcomes and, more importantly, whether outcomes can be improved by modifying these measures with targeted interventions. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Matthew D McElvany
- M. D. McElvany, Department of Orthopaedics, The Permanente Medical Group, Santa Rosa, CA, USA P. H. Chan, H. A. Prentice, E. W. Paxton, Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA M. T. Dillon, Department of Orthopaedics, The Permanente Medical Group, Sacramento, CA, USA R. A. Navarro, Department of Orthopaedics, Southern California Permanente Medical Group, Harbor City, CA, USA
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Singh A, Schultzel M, Cafri G, Yian EH, Dillon MT, Navarro RA. Risk Factors for Mortality and Readmission After Shoulder Hemiarthroplasty for Fracture. J Shoulder Elb Arthroplast 2019; 3:2471549219840441. [PMID: 34497948 PMCID: PMC8282164 DOI: 10.1177/2471549219840441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 02/18/2019] [Accepted: 03/06/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Limited information exists regarding mortality and readmission following proximal humerus fracture. This study examines risk factors following hemiarthroplasty for these fractures. METHODS A retrospective analysis of prospectively collected data on 788 patients treated with hemiarthroplasty for acute proximal humerus fracture from January 2005 to December 2011 was conducted. One-year mortality and 30- and 90-day hospital readmission were evaluated. Patient risk factors included age, race, gender, diabetes, American Society of Anesthesiologists (ASA) score, and body mass index. RESULTS One-year mortality rate was 5.2%. Patients with ASA ≥3 had 2.37 times (95% confidence interval [CI]: 1.05-5.32) greater mortality risk versus patients with ASA1/2. The 30-day readmission rate was 8.4% and at 90 days was 12.6%. Females had 0.53 risk of readmission versus males (95% CI: 0.29-0.96). Patients with ASA ≥3 had 1.79 (95% CI: 1.04-3.09) risk of 90-day readmission versus patients with ASA1/2; females had 0.52 (95% CI: 0.31-0.85) risk of readmission versus males. Increased age increased all odds ratios. CONCLUSIONS Readmission rate after hemiarthroplasty for proximal humerus fracture is significant both at 30 and 90 days and is higher in males. Age and ASA ≥3 correlate with this. Diabetes and obesity were not significant risk factors for readmission or mortality.
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Affiliation(s)
- Anshuman Singh
- Southern California Permanente Medical Group, Department of Orthopaedics, San Diego, California
| | - Mark Schultzel
- Southern California Permanente Medical Group, Department of Orthopaedics, San Diego, California
| | - Guy Cafri
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Edward H Yian
- Southern California Permanente Medical Group, Department of Orthopaedics, Anaheim, California
| | - Mark T Dillon
- The Permanente Medical Group, Department of Orthopaedics, Sacramento, California
| | - Ronald A Navarro
- Southern California Permanente Medical Group, Department of Orthopaedics, Torrance, California
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Dillon MT, Prentice HA, Burfeind WE, Chan PH, Navarro RA. The increasing role of reverse total shoulder arthroplasty in the treatment of proximal humerus fractures. Injury 2019; 50:676-680. [PMID: 30738568 DOI: 10.1016/j.injury.2019.01.034] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/26/2019] [Accepted: 01/29/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hemiarthroplasty of the shoulder is a well established treatment for proximal humerus fractures not amenable to open reduction internal fixation. However, orthopedic surgeons have recently increased utilization of reverse total shoulder arthroplasty (RTSA) in the treatment of these injuries. The purpose of this study was to evaluate the use of hemiarthroplasty and RTSA between 2009 and 2016 for the treatment of proximal humerus fractures within a large United States integrated healthcare system. MATERIALS AND METHODS A descriptive study was conducted using our integrated healthcare system's Shoulder Arthroplasty Registry. Shoulder arthroplasty cases performed for an acute proximal humerus fracture between the years of 2009 and 2016 were identified. Revision rates were determined, as well as changes in age and gender distribution of the cohort during the study period. RESULTS In 2015, RTSA utilization surpassed that of hemiarthroplasty for the first time in the healthcare system. The utilization of RTSA in the treatment of proximal humerus fractures increased from 4.5% of all arthroplasties in 2009 to 67.4% of arthroplasties in 2016. During the study period, patients undergoing hemiarthroplasty were younger and less likely to be female. Crude revision rate was 4.0% for hemiarthroplasty and 3.2% for RTSA. CONCLUSIONS RTSA is increasingly being utilized for the treatment of proximal humerus fractures and now appears to be the treatment of choice. While hemiarthroplasty appears to be falling out of favor in the treatment of fractures of the shoulder, surgeons may still be preferentially using the procedure in younger patients.
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Affiliation(s)
- Mark T Dillon
- Department of Orthopedic Surgery, The Permanente Medical Group, Sacramento, CA, USA.
| | | | | | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | - Ronald A Navarro
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Harbor City, CA USA
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Rao AG, Chan PH, Prentice HA, Paxton EW, Navarro RA, Dillon MT, Singh A. Risk factors for postoperative opioid use after elective shoulder arthroplasty. J Shoulder Elbow Surg 2018; 27:1960-1968. [PMID: 29891412 DOI: 10.1016/j.jse.2018.04.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/24/2018] [Accepted: 04/27/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The opioid epidemic remains a serious issue in the United States with significant impact to the medical and socioeconomic welfare of communities. We sought to determine baseline opioid use in patients undergoing shoulder arthroplasty (SA) and identify patient characteristics, comorbidities, and surgical risk factors associated with postoperative opioid use. METHODS A Shoulder Arthroplasty Registry identified the number of dispensed opioid medication prescriptions (Rxs) in the first postoperative year in patients who underwent elective primary SA from 2008 to 2014. We used Poisson regression to study the effect of preoperative risks factors on number of dispensed opioid Rxs in the first postoperative year, evaluated quarterly (Q1: days 0-90, Q2: days 91-180, Q3: days 181-270, Q4: days 271-360). RESULTS Included were 4243 SAs from 3996 patients, and 75% used opioids in the 1-year preoperative period. The factors associated with increased opioid use in all postoperative quarters (Q4 incident rate ratio [IRR] shown) were age <60 years (IRR, 1.40; 95% confidence interval [CI], 1.29-1.51), preoperative opioid use (1-4 Rxs: IRR, 2.15; 95% CI, 1.85-2.51; ≥5 Rxs: IRR, 9.83; 95% CI , 8.53-11.32), anxiety (IRR, 1.11; 95% CI, 1.03-1.20), opioid dependence (IRR, 1.23; 95% CI, 1.05-1.43), substance abuse (IRR, 1.17; 95% CI, 1.07-1.28), and general chronic pain (IRR, 1.38; 95% CI, 1.28-1.50). CONCLUSION Opioid usage in patients undergoing SA is widespread at 1 year, with three-fourths of patients having been dispensed at least one Rx. These findings emphasize the need for surgeon and patient awareness as well as education in the management of postoperative opioid usage associated with the indicated conditions. Surgeons may consider these risk factors for preoperative risk stratification and targeted deployment of preventative strategies.
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Affiliation(s)
- Anita G Rao
- Department of Orthopaedic Surgery, Northwest Permanente Medical Group, Portland, OR, USA.
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | | | | | - Ronald A Navarro
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, Harbor City, CA, USA
| | - Mark T Dillon
- Department of Orthopaedic Surgery, The Permanente Medical Group, Sacramento, CA, USA
| | - Anshuman Singh
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, San Diego, CA, USA
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Okike K, Chan PH, Prentice HA, Paxton EW, Navarro RA. Association Between Race and Ethnicity and Hip Fracture Outcomes in a Universally Insured Population. J Bone Joint Surg Am 2018; 100:1126-1131. [PMID: 29975273 DOI: 10.2106/jbjs.17.01178] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prior studies have documented racial and ethnic disparities in hip fracture treatment and outcome, and unequal access is commonly cited as a potential mediator. We sought to assess whether disparities in hip fracture outcome persist within a universally insured population of patients enrolled in a managed health-care system. METHODS A U.S. integrated health systems registry was used to identify patients who underwent treatment for a hip fracture when they were ≥60 years of age from 2009 to 2014. Patient demographics, procedure details, and outcomes were obtained from the registry. Differences in outcome according to race/ethnicity were analyzed using multivariable regression analysis with adjustment for socioeconomic status and other potential confounders. RESULTS Of 17,790 patients, 79.4% were white, 3.9% were black, 9.4% were Hispanic, and 7.4% were Asian. Compared with white patients, black patients had a similar 1-year mortality rate (odds ratio [OR] = 0.93, 95% confidence interval [CI] = 0.79 to 1.09, p = 0.37), Hispanic patients had a lower rate (OR = 0.85, 95% = CI = 0.75 to 0.96, p = 0.01), and Asian patients also had a lower rate (OR = 0.65, 95% CI = 0.56 to 0.76, p < 0.001). There were no differences in terms of surgical delay, 90-day emergency department visits, or reoperations during the patient's lifetime (p > 0.05) between the groups. Compared with white patients, black and Hispanic patients had fewer 90-day postoperative complications (p = 0.04 and p = 0.01, respectively); 90-day unplanned readmissions were less common among Asian patients (p = 0.03) but more common among black patients (p = 0.01). CONCLUSIONS In this study of hip fractures treated in an integrated managed care system, minority patients were found to have postoperative mortality rates that were similar to, or lower than, those of white patients. These findings may be related to the equal access and/or standardized protocols associated with treatment in this managed care system. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kanu Okike
- Department of Orthopaedics, Kaiser Moanalua Medical Center, Honolulu, Hawaii
| | - Priscilla H Chan
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Heather A Prentice
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California
| | - Ronald A Navarro
- Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, California
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Navarro RA, Lin CC, Foroohar A, Crain SR, Hall MP. Unplanned emergency department or urgent care visits after outpatient rotator cuff repair: potential for avoidance. J Shoulder Elbow Surg 2018; 27:993-997. [PMID: 29361411 DOI: 10.1016/j.jse.2017.12.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 11/22/2017] [Accepted: 12/03/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND With the cost of health care rising, the potential to avoid costs from an unplanned return to the emergency department (ED) or urgent care center (UC) after elective outpatient rotator cuff repair (RCR) has been discussed but not extensively assessed. METHODS Outpatient RCR procedures were queried in a closed health care system, and all unplanned ED and UC visits within 7 days of procedures were collected and compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction). Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention. Final tallies of all visits versus visits with ADs were compared. RESULTS From June 2015 to May 2016, 1306 outpatient RCRs were performed (729 male and 577 female patients; average age, 60 years). Of the patients, 90 returned for ED or UC visits (6.9%), with 34 for ADs (2.6%). Pain was the most common AD. However, when RCR was compared with other case types, ED or UC visits for urinary retention were significantly more common (P = .007), whereas there was no significant difference with the other ADs. The 1306 RCRs led to a greater proportion of ED or UC visits than the combined 5825 other cases studied (P < .001). DISCUSSION AND CONCLUSIONS Unplanned ED visits within 7 days of outpatient RCR are measurable and in many cases, such as ED or UC visits for pain, are avoidable. Visits for urinary retention are seen more commonly after RCR. Outpatient RCR led to more unplanned ED and UC visits than other common outpatient orthopedic surgical procedures.
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Affiliation(s)
- Ronald A Navarro
- Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, CA, USA.
| | - Charles C Lin
- University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Abtin Foroohar
- Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, CA, USA
| | - Steven R Crain
- Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, CA, USA
| | - Michael P Hall
- Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, CA, USA
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Abstract
BACKGROUND Distal triceps tendon ruptures are rare. The authors present a series of 184 surgically treated, acute, traumatic triceps tendon avulsions and compare the complications between those treated with anchors (A) versus transosseous (TO) suture repair. HYPOTHESIS No difference exists in the retear rate between TO and A repairs. Study Designed: Cohort study; Level of evidence, 3. METHODS All patients who underwent an open primary repair of a traumatic triceps tendon avulsion within 90 days of injury, between 2007 and 2015, were retrospectively reviewed. Surgeries were performed within a multisurgeon (75 surgeons), multicenter (14 centers), community-based integrated health care system. Patient demographic information, type of repair, complications, and time from surgery to release from medical care were recorded. RESULTS 184 triceps tears in 181 patients met the inclusion criteria. The mean age was 49 years (range, 15-83 years). There were 169 males. The most common mechanisms of injury were fall (56.5%) and weight lifting (19%). Mean time from injury to surgery was 19 days (range, 1-90 days); in 74.5% of cases, surgery was performed in 3 weeks or less. There were 105 TO and 73 A repairs. No significant difference was found between the two groups in the mean age ( P = .18), sex ( P = .51), completeness of tears ( P = .74), tourniquet time ( P = .455), and prevalence of smokers ( P = .64). Significant differences were noted between TO and A repairs in terms of reruptures (6.7% vs 0%, respectively; P = .0244), overall reoperation rate (9.5% vs 1.4%; P = .026), and release from medical care (4.3 vs 3.4 months; P = .0014), but no difference was seen in infection rate (3.8% vs 0%; P = .092). No difference was noted in release from medical care in patients who underwent surgery 3 weeks or less after injury compared with those undergoing surgery more than 3 weeks after injury (3.90 vs 4.09 months, respectively; P = .911). CONCLUSION Primary repair of triceps ruptures with TO fixation has a significantly higher rerupture rate, higher reoperation rate, and longer release from medical care than does repair with A fixation. Implementation of suture anchors in triceps repairs offers a lower complication rate and earlier release from medical care.
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Affiliation(s)
- Raffy Mirzayan
- Kaiser Permanente Southern California, Baldwin Park, California, USA
| | - Daniel C Acevedo
- Kaiser Permanente Southern California, Panorama City, California, USA
| | - Jeffrey F Sodl
- Kaiser Permanente Southern California, Orange County, California, USA
| | - Edward H Yian
- Kaiser Permanente Southern California, Orange County, California, USA
| | - Ronald A Navarro
- Kaiser Permanente Southern California, South Bay, California, USA
| | | | - Anshuman Singh
- Kaiser Permanente Southern California, San Diego, California, USA
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Inacio MCS, Dillon MT, Miric A, Navarro RA, Paxton EW. Mortality After Total Knee and Total Hip Arthroplasty in a Large Integrated Health Care System. Perm J 2018; 21:16-171. [PMID: 28746022 DOI: 10.7812/tpp/16-171] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT The number of excess deaths associated with elective total joint arthroplasty in the US is not well understood. OBJECTIVE To evaluate one-year postoperative mortality among patients with elective primary and revision arthroplasty procedures of the hip and knee. DESIGN A retrospective analysis was conducted of hip and knee arthroplasties performed in 2010. Procedure type, procedure volume, patient age and sex, and mortality were obtained from an institutional total joint replacement registry. An integrated health care system population was the sampling frame for the study subjects and was the reference group for the study. MAIN OUTCOME MEASURES Standardized 1-year mortality ratios (SMRs) and 95% confidence intervals (CIs) were calculated. RESULTS A total of 10,163 primary total knee arthroplasties (TKAs), 4963 primary total hip arthroplasties (THAs), 606 revision TKAs, and 496 revision THAs were evaluated. Patients undergoing primary THA (SMR = 0.6, 95% CI = 0.4-0.7) and TKA (SMR = 0.4, 95% CI = 0.3-0.5) had lower odds of mortality than expected. Patients with revision TKA had higher-than-expected mortality odds (SMR = 1.8, 95% CI = 1.1-2.5), whereas patients with revision THA (SMR = 0.9, 95% CI = 0.4-1.5) did not have higher-than-expected odds of mortality. CONCLUSION Understanding excess mortality after joint surgery allows clinicians to evaluate current practices and to determine whether certain groups are at higher-than-expected mortality risk after surgery.
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Affiliation(s)
- Maria C S Inacio
- Epidemiologist in the Surgical Outcomes and Analysis Department at Kaiser Permanente in San Diego, CA.
| | - Mark T Dillon
- Orthopedic Surgeon at the Sacramento Medical Center in CA.
| | - Alex Miric
- Orthopedic Surgeon at the Sunset Medical Center in Los Angeles, CA.
| | | | - Elizabeth W Paxton
- Director of the Surgical Outcomes and Analysis Department at Kaiser Permanente in San Diego, CA.
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Norheim EP, Black MH, Ngor EW, Shi JM, Safran MR, Navarro RA. Cervical spine disease in surgeons performing arthroscopy or laparoscopy. Arch Environ Occup Health 2017; 74:206-214. [PMID: 29035681 DOI: 10.1080/19338244.2017.1392277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/06/2017] [Indexed: 06/07/2023]
Abstract
Minimal research exists regarding cervical spine disorders in surgeons who perform endoscopy. A confidential on-line survey regarding neck pain (NP), spine disease (SD), and radiculopathy/myelopathy (R/M) was sent to 722 surgeons from a managed, group-based health care system. 415 responded. 361 had endoscopy experience, of whom 24.4% had NP, 20.8% SD, and 3.9% R/M. Most respondents were less than 50 years of age (62.3%), and male (65.7%). Significant risk factors for NP included older age and female, whereas OB/Gyn specialty, increased age and job stress were for SD. After adjusting for age and gender, significant risk factors for NP and SD included greater surgeon experience. After also adjusting for job stress, significant risk factors for SD included increased surgeon experience and higher frequency of endoscopies. No association was found between use of digital OR. Endoscopy appears to place surgeons at higher risk of cervical disease. Level of Evidence: Level 3.
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Affiliation(s)
- Elizabeth P Norheim
- a Southern California Permanente Medical Group, Kaiser Permanente, Downey Medical Center, Spine Surgery , Downey , California , USA
| | | | - Eunis W Ngor
- b Kaiser Foundation Health Plan , Pasadena , California , USA
| | - Jiaxiao M Shi
- b Kaiser Foundation Health Plan , Pasadena , California , USA
| | - Marc R Safran
- c Stanford Hospital and Clinics , Stanford , California , USA
| | - Ronald A Navarro
- d Southern California Permanente Medical Group, Kaiser Permanente, South Bay Medical Center , Harbor City , California , USA
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