Complications and Unsuccessful Same-Day Discharge Following Outpatient Total Hip Arthroplasty (THA) in the Medicare Population: Incidence, Risk Factors, and Clinical Impact

2021 ◽  
Author(s):  
Adam M. Gordon ◽  
Azeem Tariq Malik
Keyword(s):  
Risk Factors ◽  
Total Hip Arthroplasty ◽  
Operative Time ◽  
Clinical Impact ◽  
Discharge Destination ◽  
Home Discharge ◽  
Same Day Discharge ◽  
Incidence Risk ◽  
American Society ◽  
American Society Of Anesthesiologists

AbstractIn 2020, total hip arthroplasty (THA) was removed from the inpatient-only list by the Centers for Medicare and Medicaid Services. The objective was to analyze outpatient THA in the Medicare population to understand incidence of failed same-day discharge (SDD) and risk factors for complications and extended length of stay (LOS). The 2015–2019 American College of Surgeons—National Surgical Quality Improvement Program database was queried for Medicare patients (≥ 65 years) undergoing outpatient THA. Short-term complications, LOS, and discharge destination were evaluated. Multivariate logistic regression was used to evaluate risk factors for complications, failed SDD, reoperation, readmission, and non-home discharge disposition. Overall, 2,063 THAs were included. Complication rate was 7.4%. The number of patients staying in the hospital ≥ 1 day was 1,080 (52%). A total of 151 patients (7.3%) experienced a non-home discharge. Predictors for having any complication was an extended LOS ≥ 1 day (odds ratio [OR] 2.86), p < 0.001. Significant predictors for failed SDD were smoking history (OR 2.25), operative time ≥ 82 minutes (OR 1.98), American Society of Anesthesiologists Class > II (OR 1.67), and age ≥ 71 (OR 1.31) (all p ≤ 0.004). Significant predictors for a non-home discharge were LOS ≥ 1 day (OR 13.71), American Society of Anesthesiologists Class > II (OR 2.36), age ≥ 71 (OR 2.07), operative time ≥ 82 minutes (OR 1.88), and female gender (OR 1.81), all p ≤ 0.003. The current study identifies the incidence, risk factors, and clinical impact of postoperative complications and prolonged LOS in Medicare-aged patients undergoing outpatient THA. Providers should consider preoperatively risk stratifying patients to reduce the costs associated with extended LOS, complication, and unplanned discharge destination.

scholarly journals Low Transfusion Rate Attainable in Anterior Approach Total Hip Arthroplasty Utilizing a Modern Protocol

2021 ◽  
Vol 11 ◽  
Author(s):  
Joseph Gondusky ◽  
Benjamin Campbell ◽  
Christian Coulson
Keyword(s):  
Total Hip Arthroplasty ◽  
Blood Loss ◽  
Hip Arthroplasty ◽  
Anterior Approach ◽  
Operative Time ◽  
Transfusion Rate ◽  
Total Hip ◽  
Estimated Blood Loss ◽  
American Society ◽  
American Society Of Anesthesiologists

Background: Transfusion is a known risk of total hip arthroplasty (THA).  It has been associated with a multitude of medical complications and increased cost.  Prior studies report transfusion rates associated with THA, with wide variation, but most cannot differentiate the surgical approach utilized.  The anterior approach (AA) for THA has been associated with increased operative time, complications, and blood loss, but little data exists regarding the actual transfusion rate associated with the approach. Methods: We performed a retrospective review of 390 consecutive, elective, primary unilateral AA THA procedures.  Patient demographic, clinical and perioperative data was analyzed.  A modern perioperative pathway, including a simple protocol to limit blood loss, is defined. Results: The group consisted of a typical inpatient arthroplasty population, with wide ranges of age, body mass index (BMI), and health status.  The average age was 64.05 years (+ 10.67, range 27-94).  BMI averaged 29.76 kg/m2 (+ 5.98, range 16-47).  The majority of patients were American Society of Anesthesiologists (ASA) class 2 (45.6%) or 3 (50.3%), with 10 patients ASA 4 (2.6%).  Average preoperative hemoglobin was 13.48 g/dL (+ 1.47, range 9.1-18.2).  Operative time averaged 91.22 minutes (+ 14.2).  83.3% of patients received a spinal anesthetic.  Most patients were discharged on postoperative day one (93.1%) to home (99%).  Estimated blood loss averaged 264mL (+ 95.19, range 100-1000).  No patient required perioperative transfusion or readmission for symptomatic anemia within 30 days postoperative.  Conclusion:  A modern protocol we utilize and define is capable of limiting blood loss and transfusion risk in anterior approach total hip arthroplasty. 

scholarly journals Risk Factors for Discharge to a Non-Home Destination and Reoperation Following Outpatient Total Hip Arthroplasty (THA) in Medicare-Eligible Patients

2021 ◽  
Vol 12 ◽  
pp. 215145932199150
Author(s):  
Adam M. Gordon ◽  
Azeem Tariq Malik ◽  
Safdar N. Khan
Keyword(s):  
Risk Factors ◽  
Total Hip Arthroplasty ◽  
Hip Arthroplasty ◽  
Care Facility ◽  
Discharge Destination ◽  
Improvement Program ◽  
Factors Associated ◽  
Total Hip ◽  
Home Discharge ◽  
Independent Risk Factors

Introduction: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only (IO) list in January 2020. Given this recommendation, we analyzed Medicare-eligible patients undergoing outpatient THA to understand risk factors for nonroutine discharge, reoperations, and readmissions. Materials and Methods: The 2015-2018 American College of Surgeons–National Surgical Quality Improvement Program database was queried using Current Procedural Terminology code 27130 for Medicare eligible patients (≥ 65 years of age) undergoing outpatient THA. Postoperative discharge destination was categorized into home and non-home. Multivariate logistic regression models were used to evaluate risk factors associated with non-home discharge disposition. Secondarily, we evaluated rates and risk factors associated with 30-day reoperations and readmissions. Results: A total of 1095 THAs were retrieved for final analysis. A total of 108 patients (9.9%) experienced a non-home discharge postoperatively. Patients were discharged to rehab (n = 47; 4.3%), a skilled care facility (n = 47; 4.3%), a facility that was “home” (n = 8; 0.7%), a separate acute care facility (n = 5; 0.5%), or an unskilled facility (n = 1; 0.1%). Independent factors for a non-home discharge were American Society of Anesthesiologists Class >II (odds ratio [OR] 2.74), operative time >80 minutes (OR 2.42), age >70 years (OR 2.20), and female gender (OR 1.67). Eighteen patients (1.6%) required an unplanned reoperation within 30 days. A total of 40 patients (3.7%) required 30-day readmissions, with 35 readmissions related to the original THA procedure. Independent risk factors for 30-day reoperation were COPD (OR 5.85) and HTN (OR 5.24). Independent risk factors for 30-day readmission were HTN (OR 4.35) and Age >70 (OR 2.48). Discussion: The current study identifies significant predictors associated with a non-home discharge, reoperation, and readmission in Medicare-aged patients undergoing outpatient THA. Conclusion: Providers should consider preoperatively risk-stratifying patients to reduce the costs associated with unplanned discharge destination, complication or reoperation.

Attending Surgeon Variation in Operative Case Length: An Opportunity for Quality Improvement

2018 ◽  
Vol 84 (10) ◽  
pp. 1595-1599
Author(s):  
Kirollos S. Malek ◽  
Jukes P. Namm ◽  
Carlos A. Garberoglio ◽  
Maheswari Senthil ◽  
Naveen Solomon ◽  
...  
Keyword(s):  
Operative Time ◽  
Resident Training ◽  
Careful Consideration ◽  
Analysis Of Covariance ◽  
Surgical Resident ◽  
Or Efficiency ◽  
American Society ◽  
Case Logs ◽  
American Society Of Anesthesiologists ◽  
The Impact

Balancing resident education with operating room (OR) efficiency, while accommodating different styles of surgical educators and learners, is a challenging task. We sought to evaluate variability in operative time for breast surgery cases. Accreditation Council for Graduate Medical Education case logs of breast operations from 2011 to 2017 for current surgical residents at Loma Linda University were correlated with patient records. The main outcome measure was operative time. Breast cases were assessed as these operations are performed during all postgraduate years (PGY). Breast procedures were grouped according to similarity. Variables analyzed included attending surgeon, PGY level, procedure type, month of operation, and American Society of Anesthesiologists class. Of 606 breast cases reviewed, median overall operative time was 150 minutes (interquartile range 187–927). One-way analysis of covariance demonstrated statistically significant variation in operative time by attending surgeon controlling for covariates (PGY level, procedure, American Society of Anesthesiologists class, and month) ( P = 0.04). With institutional OR costs of $30 per minute, the average difference between slowest and fastest surgeon was $2400 per case [(218–138) minutes 3 $30/min]. Minimizing variability for common procedures performed by surgical educators may enhance OR efficiency. However, the impact of case length on surgical resident training requires careful consideration.

scholarly journals Risk Factors and Indications for 30-Day Readmission After Primary Surgery for Epithelial Ovarian Cancer

2015 ◽  
Vol 25 (2) ◽  
pp. 193-202 ◽  
Author(s):  
Mariam AlHilli ◽  
Carrie Langstraat ◽  
Christine Tran ◽  
Janice Martin ◽  
Amy Weaver ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ovarian Cancer ◽  
Postoperative Complications ◽  
Epithelial Ovarian Cancer ◽  
Odds Ratio ◽  
Residual Disease ◽  
Factors Associated ◽  
Primary Surgery ◽  
American Society ◽  
American Society Of Anesthesiologists

BackgroundTo identify patients at risk for postoperative morbidities, we evaluated indications and factors associated with 30-day readmission after epithelial ovarian cancer surgery.MethodsPatients undergoing primary surgery for epithelial ovarian cancer between January 2, 2003, and December 29, 2008, were evaluated. Univariable and multivariable logistic regression models were fit to identify factors associated with 30-day readmission. A parsimonious multivariable model was identified using backward and stepwise variable selection.ResultsIn total, 324 (60.2%) patients were stage III and 91 (16.9%) were stage IV. Of all 538 eligible patients, 104 (19.3%) were readmitted within 30 days. Cytoreduction to no residual disease was achieved in 300 (55.8%) patients, and 167 (31.0%) had measurable disease (≤1 cm residual disease). The most common indications for readmission were surgical site infection (SSI; 21.2%), pleural effusion/ascites management (14.4%), and thromboembolic events (12.5%). Multivariate analysis identified American Society of Anesthesiologists score of 3 or higher (odds ratio, 1.85; 95% confidence interval, 1.18–2.89;P= 0.007), ascites [1.76 (1.11–2.81);P= 0.02], and postoperative complications during initial admission [grade 3–5 vs none, 2.47 (1.19–5.16); grade 1 vs none, 2.19 (0.98–4.85); grade 2 vs none, 1.28 (0.74–2.21);P= 0.048] to be independently associated with 30-day readmission (c-index = 0.625). Chronic obstructive pulmonary disease was the sole predictor of readmission for SSI (odds ratio, 3.92; 95% confidence interval, 1.07–4.33;P= 0.04).ConclusionsClinically significant risk factors for 30-day readmission include American Society of Anesthesiologists score of 3 or higher, ascites and postoperative complications at initial admission. The SSI and pleural effusions/ascites are common indications for readmission. Systems can be developed to predict patients needing outpatient management, improve care, and reduce costs.

scholarly journals The Paisley Pattern Breast Reduction

2019 ◽  
Vol 27 (2) ◽  
pp. 189-194
Author(s):  
Devra B. Becker
Keyword(s):  
Chart Review ◽  
Operative Time ◽  
Breast Reduction ◽  
Proof Of Concept ◽  
Flap Necrosis ◽  
Institutional Review ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Wise Pattern

Background: Skin resection patterns inform the shape and scars after breast reduction. The 2 most commonly performed skin resection patterns, the Wise pattern and vertical pattern, each have limitations. The most common challenge is addressing excess lateral skin while avoiding medial scars. The Paisley Pattern breast reduction addresses this by incorporating lateral dogear excision in the skin resection design. Methods: Thirty consecutive patients received a Paisley Pattern breast reduction. After institutional review board approval, a chart review was performed to evaluate resection weight, operative time, American Society of Anesthesiologists class, flap necrosis, and seroma. Results: Operative times were comparable to published times for the Wise and vertical pattern techniques. No patients had lateral flap necrosis, and no patients required a return to the operating room during the follow-up period. One patient developed a unilateral seroma that was drained by interventional radiology. Conclusions: This report of a novel skin resection design demonstrates a proof of concept that the skin resection pattern can be performed safely in a wide variety of patients. Although there is a learning curve to the technique to prevent over-resection laterally, it provides efficient and aesthetically acceptable alternative to the Wise and vertical skin resection patterns for both large and small reductions.

Reasons for 30-day Postoperative Readmissions for Medicare Patients at a Community-based Teaching Hospital

2015 ◽  
Vol 81 (4) ◽  
pp. 381-386
Author(s):  
Jennifer L. Kirsch ◽  
Shanu N. Kothari ◽  
Janelle M. Ausloos ◽  
Jacob D. Gundrum ◽  
Kara J. Kallies
Keyword(s):  
Length Of Stay ◽  
Operative Time ◽  
Reform Initiatives ◽  
Readmission Rates ◽  
Community Based ◽  
Related Factors ◽  
Medicare Patients ◽  
Patient Noncompliance ◽  
American Society ◽  
American Society Of Anesthesiologists

Healthcare reform initiatives have proposed reducing reimbursement for certain 30-day readmissions among Medicare patients. Our objective was to evaluate the incidence and reasons for 30-day postoperative readmissions at our institution. The medical records of Medicare patients who underwent surgery from January 1, 2010, through May 16, 2011, were reviewed. Statistical analysis included χ2, Wilcoxon rank sum, and t tests. Two thousand eight hundred sixty-five patients were included; 199 (7%) had a 30-day readmission. The readmission group included a higher proportion of men (53.8 vs 43.6%, P = 0.005), and patients with an American Society of Anesthesiologists (ASA) Class 3 or greater (84 vs 66%, P < 0.001) versus the nonreadmission group. Mean index length of stay and operative time were longer in the readmitted versus nonreadmitted group (4.8 vs 2.8 days, P < 0.001; 122.8 vs 98.2 minutes, P < 0.001). Readmission reasons were surgically related (53%), surgically unrelated (35%), planned (7%), and patient-related (5%). Higher 30-day postoperative readmission rates were associated with male sex, higher ASA class, and longer index length of stay and operative time. Reasons for readmission included surgical- and patient-related factors. Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance.

Outbreak ofShewanella algaeandShewanella putrefaciensInfections Caused by a Shared Measuring Cup in a General Surgery Unit in Korea

2008 ◽  
Vol 29 (8) ◽  
pp. 742-748 ◽  
Author(s):  
Hyang Soon Oh ◽  
Kyung Ah Kum ◽  
Eui-Chong Kim ◽  
Hoan-Jong Lee ◽  
Kang Won Choe ◽  
...  
Keyword(s):  
Risk Factors ◽  
Acute Care Hospital ◽  
Surveillance Systems ◽  
Care Hospital ◽  
Human Pathogens ◽  
Logistic Analysis ◽  
Before And After ◽  
Contact Transmission ◽  
American Society ◽  
American Society Of Anesthesiologists

Objective.To control an outbreak ofShewanella algaeandS. putrefaciensinfections by identifying the risk factors for infection and transmission.Design.Matched case-control study.Setting.A university-affiliated tertiary acute care hospital in Seoul, Republic of Korea, with approximately 1,600 beds.Patients.From June 20, 2003, to January 16, 2004, a total of 31 case patients withShewanellacolonization or infection and 62 control patients were enrolled in the study.Interventions.Requirement to use single-use measuring cups and standard precautions (including hand washing before and after patient care and use of gloves).Results.S. algaeorS. putrefacienswas isolated from blood, for 9 (29.0%) of 31 patients who acquired one of the organisms; from bile, for 8 (25.8%), and from ascitic fluid, for 8 (25.8%). The attack rate of this outbreak was 5.8% (31 patients infected or colonized, of 534 potentially exposed on ward A) and the pathogenicity of the two species together was 77.4% (24 patients infected, of 31 who acquired the pathogens). The estimated incubation period forShewanellaacquisition was 3–49 days. Using logistic analysis, we identified the following risk factors: presence of external drainage catheters in the hepatobiliary system (odds ratio [OR], 20;P< .001), presence of hepatobiliary disease (OR, 6.4;P< .001), admission to the emergency department of the hospital (OR, 2.9;P= .039), wound classification of “contaminated” or “dirty or infected” (OR, 16.5;P= .012), an American Society of Anesthesiologists score of 3 or higher (OR, 8.0;P= .006), duration of stay in ward A (OR, 1.1;P< .001), and, for women, an age of 60–69 years (OR, 13.3;P= .028). AShewanellaisolate was recovered from the surface of a shared measuring cup, and 12 isolates ofS. algaeshowed the same pulsed-field gel electrophoresis pattern.Conclusions.ThisShewanellaoutbreak had a single-source origin and spread by contact transmission via a contaminated measuring cup.Shewanellaspecies are emerging as potentially serious human pathogens in hospitals and could be included in hospital infection surveillance systems.

Low incidence of postoperative nausea, vomiting, regurgitation, and aspiration pneumonia in geriatric dogs receiving maropitant, famotidine, and fentanyl as part of an anesthesia protocol

2021 ◽  
Vol 260 (S1) ◽  
pp. S46-S51
Author(s):  
Ashley L. Moyer ◽  
Talon S. McKee ◽  
Philip J. Bergman ◽  
Arathi Vinayak
Keyword(s):  
Risk Factors ◽  
Aspiration Pneumonia ◽  
Postoperative Nausea ◽  
Postoperative Nausea And Vomiting ◽  
Asa Score ◽  
Surgery Patient ◽  
Potential Risk Factors ◽  
Low Incidence ◽  
American Society ◽  
American Society Of Anesthesiologists

Abstract OBJECTIVE To determine the incidence of and potential risk factors for postoperative regurgitation and vomiting (PORV), postoperative nausea and vomiting (PONV), and aspiration pneumonia in geriatric dogs using premedication with maropitant and famotidine, intraoperative fentanyl, and postoperative fentanyl as part of an anesthetic protocol. ANIMALS 105 client-owned geriatric dogs that underwent general anesthesia for a major surgical procedure between January 2019 and March 2020. PROCEDURES Medical records were reviewed to collect data on signalment, historical gastrointestinal signs, American Society of Anesthesiologists (ASA) score, indication for surgery, duration of anesthesia and surgery, patient position during surgery, mode of ventilation, and perioperative administration of maropitant, famotidine, anticholinergics, opioids, colloidal support, NSAID, corticosteroids, and appetite stimulants. The incidence of postoperative regurgitation, vomiting, nausea, and aspiration pneumonia was calculated, and variables were each analyzed for their association with these outcomes. RESULTS 2 of 105 (1.9%) dogs regurgitated, 1 of 105 (1.0%) dogs developed aspiration pneumonia, 4 of 105 (3.8%) dogs exhibited nausea, and no dogs vomited. Identified possible risk factors included older age (≥ 13 years old) for postoperative regurgitation, regurgitation for postoperative aspiration pneumonia, and high ASA score (≥ 4) for both regurgitation and aspiration pneumonia. CONCLUSIONS AND CLINICAL RELEVANCE The use of an antiemetic protocol including maropitant, famotidine, and fentanyl in geriatric dogs resulted in very low incidences of PORV, PONV, and aspiration pneumonia. Future prospective studies are warranted to further evaluate and mitigate postoperative risks.

Are Orthopedic Hand Surgeons Undercompensated for Time Spent in the Operating Room? A Study of Relative Value Units

Hand ◽  
2022 ◽  
pp. 155894472110643
Author(s):  
Trevor Simcox ◽  
Sakib Safi ◽  
Jacob Becker ◽  
Jason Kreinces ◽  
Adam Wilson
Keyword(s):  
Complication Rate ◽  
Operative Time ◽  
Major Complication ◽  
Hand Surgery ◽  
Reoperation Rate ◽  
Orthopedic Procedures ◽  
Improvement Program ◽  
Relative Value ◽  
American Society ◽  
American Society Of Anesthesiologists

Background: This study aims to investigate whether compensation is equitable among the most commonly performed orthopedic hand surgeries and when compared with general orthopedic procedures. Methods: The National Surgical Quality Improvement Program database was queried for all orthopedic procedures, from 2016 to 2018, performed more than 150 times using Current Procedural Terminology (CPT) codes. Physician work relative value unit (wRVU) data were obtained from the 2020 US Centers for Medicare and Medicaid Services fee schedule. Linear regressions were used to determine whether there was an association among wRVU, operative time, and wRVU per hour (wRVU/h). Reimbursement for hand surgery CPT codes was compared with that of nonhand orthopedic CPT codes. The CPT codes were stratified into quartile cohorts based on mean operative time, major complication rate, mortality rate, American Society of Anesthesiologists class, reoperation rate, and readmission rate. Student t tests were used to compare wRVU/h between cohorts. Results: Forty-two hand CPT codes were identified from 214 orthopedic CPT codes, accounting for 32 333 hand procedures. The median wRVU/h was significantly lower for procedures in the longest operative time quartile compared with the shortest operative time quartile ( P < .001). Compared with hand procedures, nonhand procedures were found to have significantly higher mean operative time ( P < .001), mean complication rate ( P < .001), mean wRVU ( P = .001), and mean wRVU/h ( P = .007). Conclusions: The 2020 Physician wRVU scale does not allocate proportional wRVUs to orthopedic hand procedures with longer mean operative times. There is a decrease in mean reimbursement rate for hand procedures with longer mean operative time. When compared with general orthopedic procedures, hand procedures have a lower mean wRVU/h and complication rate.

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