An ACS-NSQIP Analysis of Unicompartmental Knee Arthroplasty Trends from 2013 to 2018

Unicompartmental knee arthroplasty (UKA) volume has increased with advances in implant design, perioperative protocols, and patient selection. This study analyzed national trends of UKA from 2013 to 2018 and the relationship between patient demographics and postoperative outcomes. Data on UKA (CPT 27446) from 2013 to 2018 was collected from the National Surgical Quality Improvement Program (NSQIP). Variables collected included patient demographics, American Society of Anesthesiology classification, functional status, NSQIP morbidity probability, operative time, length of stay, 30-day reoperation, and readmission rates. There was an increase in outpatient UKAs performed (920 in 2013; 11,080 in 2018) (p < 0.0001). Analysis of variance from 2013 to 2018 revealed significant decrease in patient body mass index (BMI) (32.5 in 2013; 31.5 in 2018) (p < 0.01) and NSQIP morbidity probability (0.014 in 2013; 0.011 in 2018) (p < 0.0001). Operative time increased (79.1 minutes in 2013; 84.4 minutes in 2018) (p < 0.01), but length of stay decreased (0.9 days in 2013; 0.5 days in 2018) (p < 0.0001). The number of all-cause and related readmissions decreased significantly (p < 0.045; p < 0.01). Age, male gender, BMI >40 and chronic obstructive pulmonary disease (COPD) were significant predictors for 30-day readmission. BMI >40 was a significant predictor for discharge destination. UKA has seen a rise in incidence from 2013 to 2018 with an increasing number of outpatient UKAs. Operative times and 30-day readmissions have both decreased in this time. BMI > 40 is predictive for discharge destination after UKA, while age, male gender, BMI >40, and COPD are independent risk factors for 30-day readmission.

Pre-fracture Mobility Using Standardized Scale as an Early Indicator of High Health Risk in Patients with a Hip Fracture

Hip fracture in older adults is associated with poor prognosis. We tested the hypothesis that a single standardized measure, pre-fracture mobility, can be used as an early indicator of patients at high health risk after a hip fracture. Analysis of prospectively collected data of older adults admitted with a hip fracture between April-2009 and June-2019 in a single NHS hospital, UK. Pre-fracture mobility status (freely mobile, mobilising outdoors with one aid or with two aids, and limited to indoors), was used to predict length of stay (LOS) and mortality in hospital, and discharge destination. Among 3073 (2231 women, 842 men) admitted from their own home (mean ± SD age = 82.7 ± 9.3 yr), 159 died and 2914 survived to discharge: 1834 back to their home, 772 to rehabilitation, 66 to residential care, 141 to nursing care and 101 to unknown destinations. Compared with LOS of 15.9 ± 15.6 days in patients who mobilised freely before fracture (reference), those who were able to mobilise outdoors with one aid stayed 3.5 days, and those with two aids or confined to indoor mobility stayed one week longer in hospital. In-patient mortality was increased among patients who mobilised outdoors with two aids: OR = 2.1 (95%CI = 1.3–3.3), and those limited to indoors: OR = 2.1 (1.3–1.5). Finally, a change in residence on discharge was more likely in those who mobilised outdoors with two aids (OR = 1.8, 95%CI = 1.2–2.6), and those limited to indoors (OR = 1.9, 95%CI = 1.2–2.9). In conclusion, pre-fracture mobility may be a useful early indicator for identifying patients at increased risk of adverse outcomes after an acute hip fracture.

Outcomes Following Acute Pulmonary Embolism in an Irish Population of over 1 Million Individuals: Opportunities for Quality Improvement and More Effective Resource Utilisation

Introduction Pulmonary embolism (PE) is a leading cause of cardiovascular morbidity worldwide. The risk of early death in the setting of untreated PE may be as high as 30%. However, diagnostic and therapeutic advances in recent years have led to a progressive decline in global PE-related mortality and recent data describing rates of in-hospital death following PE suggest a mortality rate of approximately 5-15%. Moreover, strategies directed at stratification of PE severity have been shown to safely identify a sub-group of low-risk patients (up to 30-50% of all patients) for whom outpatient management is feasible without the need for hospital admission. Avoiding hospitalisation for low-risk PE patients is associated with improved patient satisfaction and avoids exposing patients to the risks associated with hospital admission. Ambulatory PE management would also be predicted to lead to significant healthcare cost-savings. However ambulatory care models for low-risk PE appear to be under-utilised despite these potential benefits. Barriers to implementation include access to outpatient follow-up services and the perceived risks associated with this model of care. The Ireland East Hospital Group (IEHG) is the largest hospital network in the Republic of Ireland, consisting of 11 hospitals (including large academic centres, community general hospitals and the national maternity hospital). The IEHG serves a population of over 1.1 million individuals. We sought to determine the frequency of admissions to hospital with PE and to assess key outcomes, including length-of-stay (LOS) and in-hospital mortality within this population. Methods Data pertaining to PE diagnosis from January 2018 to December 2020 were obtained from NQAIS Clinical (National Quality Assessment and Improvement System; an electronic reporting tool which is populated with anonymised data extracted from the hospital in-patient enquiry system). This system compiles diagnostic data on all patients by ICD-10 code at the time of discharge. For the purposes of this analysis the ICD-10 codes I26.0 and I26.9 were used to identify patients with PE and only admission episodes where PE was the primary diagnosis were included; cases of 'secondary PE' (historical PE or hospital-acquired) were excluded. Projected population figures, extrapolated from Census 2016 data, were obtained from Health Atlas Ireland (an open-source application providing access to datasets developed by the Health Intelligence Unit of the Health Service Executive of Ireland). Results During the 3-year study period, 958 in-patient episodes occurred where PE was recorded as the primary diagnosis, corresponding to an incidence of 0.37 per 1000 adults per annum (95% CI 0.35 to 0.40). The incidence was highest in the over 85 years age-group (1.07 per 1000 per annum; 95% CI 0.80 to 1.33). PE was more common in women in all age-groups apart from the 46-65 years age group [males: 0.51 (95% CI 0.44-0.51) vs females: 0.36 (95% CI 0.3-0.42) per 1000]. In 82.7% of episodes, the ultimate discharge destination was to home. In 5.3% the discharge destination was a nursing home and 4.6% were transferred to another hospital. The all-cause in-hospital mortality rate was 3.1% (30 fatalities; 18 females, 12 males). Most deaths occurred in the 66-85 years age-group (n=14), with 9 fatalities in the age &gt;85 years group and 7 fatal PE events in the 46-65 years age-group. Average hospital LOS was 7.8 days. 8.9% of inpatient episodes resulted in same-day discharge. In 55.9% of episodes, discharge occurred after day 4. Those discharged to home had an average length of stay of 6.31 days, while patients awaiting nursing home facilities averaged 26.5 days. Conclusion The incidence of acute presentation with PE within this population is consistent with international reports. The rate of in-hospital mortality compares favourably with these international standards. The mortality rate may reflect improvements in PE care but may also reflect the inclusion of a significant number of 'low-risk' individuals in the analysis (many of whom may have been suitable for outpatient management). The mortality rate might also reflect increased detection of small, low-risk distal PE (as a result of advances in diagnostics). In any event, these data suggest that more widespread implementation of outpatient PE management is likely to be feasible and would represent an opportunity for improved resource utilisation. Disclosures Ni Ainle: Leo Pharma: Research Funding; Actelion: Research Funding; Daiichi-Sankyo: Research Funding; Bayer Pharma: Research Funding. Kevane: Leo Pharma: Research Funding.