What are the rates and causes of hospital readmission after total knee arthroplasty?

Background: Total knee arthroplasty (TKA) and related interventions such as revision TKA and the treatment of infected TKAs are commonly performed procedures. Hospital readmission rates are used to measure hospital performance, but risk factors (both medical and surgical) for readmission after TKA, revision TKA, and treatment for the infected TKA have not been well characterized.

Questions/purposes: We measured (1) the unplanned hospital readmission rate in primary TKA and revision TKA, including antibiotic-spacer staged revision TKA to treat infection.

Targeted use of vancomycin as perioperative prophylaxis reduces periprosthetic joint infection in revision TKA.

Background: The role of vancomycin in surgical antimicrobial prophylaxis and high-risk patients who are most likely to benefit remains unclear.

Questions/purposes: We determined the impact of targeted use of vancomycin on (1) the incidence of periprosthetic joint infection (PJI); and (2) the incidence of PJI from methicillin-resistant organisms in patients undergoing revision total knee arthroplasty (TKA) at our institution.

Methods: In an effort to reduce PJI rates, we added vancomycin to cefazolin as surgical antimicrobial prophylaxis for patients undergoing revision TKA in October 2010.

Health policy implications of outcomes measurement in orthopaedics.

An emphasis on "value" over volume in health care is driving new healthcare measurement, delivery, and payment models. Orthopaedic surgery is a major contributor to healthcare spending and, as such, is the focus of many of these new models. WHERE ARE WE NOW?: An evaluation of "value" in orthopaedics requires information that has not traditionally been collected as part of routine clinical practice.

Healthcare technology: physician collaboration in reducing the surgical cost.

Background: The increasing cost of providing health care is a national concern. Healthcare spending related to providing hospital care is one of the primary drivers of healthcare spending in the United States. Adoption of advanced medical technologies accounts for the largest percentage of growth in healthcare spending in the United States when compared with other developed countries.

The emerging case for shared decision making in orthopaedics.

The Institute of Medicine outlined a standard for patient-centered care, which has become the centerpiece of healthcare reform in the United States. Shared decision-making interventions, which include decision and communication aids, are formal embodiment of this philosophy. Although the concept of shared decision making has been shown to be an effective tool, and its relevance to orthopaedic medicine has been well documented, it has not been widely adopted by orthopaedic surgeons.

The predictors of outcome in total knee arthroplasty for post-traumatic arthritis.

Background: The outcomes of total knee arthroplasty (TKA) for post-traumatic arthritis are less reliable than for idiopathic osteoarthritis. These patients tend to be younger, present with varying degrees of deformity, and often have a history of prior surgery, resulting in a wide spectrum of pathology. We hypothesized that preoperative variables, in particular the location of deformity, would predict pain and functional outcomes.

Quality in orthopaedic surgery--an international perspective: AOA critical issues.

Quality is a hallmark of health care, although it is difficult to come to a consensus on who gets to define what "quality health care" is. Most health-care workers enter this field with the goal of improving the health of their patients (and the community), and while everyone tries to do the best job possible, we must continuously seek better methods and techniques for achieving better outcomes. The passion for continuous improvement is fundamental, but passion is not sufficient by itself.

Electronic Data Capture through Total Joint Replacement Registries.

The move toward adoption and implementation of electronic health records (EHR) provides an opportunity in the United States to use electronic clinical data (ECD) to better understand patient outcomes and to improve the quality and efficiency of medical care. Within the field of orthopedics, national joint replacement registries have been shown in other countries to improve clinical decision-making and outcomes after joint arthroplasty. Thus, there is increasing interest among U.

Factors driving physician-hospital alignment in orthopaedic surgery.

Background: The relationships between physicians and hospitals are viewed as central to the proposition of delivering high-quality health care at a sustainable cost. Over the last two decades, major changes in the scope, breadth, and complexities of these relationships have emerged. Despite understanding the need for physician-hospital alignment, identification and understanding the incentives and drivers of alignment prove challenging.

Forensic aspect of late subjective complaints after traumatic brain injury.

Background: The subjective complaints in patients with TBI (Traumatic Brain Injury) may persist for years. The most frequent complaints are headache, dizziness, drowsiness, mood disturbances, and memory and concentration disturbances. It is assumed that these complaints are caused by injury itself on one hand and psychological, emotional and motivation factors on the other.

Estimating risk in Medicare patients with THA: an electronic risk calculator for periprosthetic joint infection and mortality.

Background: Although risk factors for periprosthetic joint infection (PJI) and mortality after total hip arthroplasty (THA) have been identified, interactions between specific patient risk factors are poorly understood. Therefore, it is difficult for surgeons to counsel patients on their individual risk of PJI or mortality after THA.

Questions/purposes: We evaluated the interaction between patient clinical and demographic factors on the risk of PJI and mortality after THA and developed an electronic risk calculator for estimating the patient-specific risk of PJI and mortality in Medicare patients with THA.

Mortality, cost, and health outcomes of total knee arthroplasty in Medicare patients.

There are little data that quantify the long term costs, mortality, and downstream disease after Total Knee Arthroplasty (TKA). The purpose of this study is to compare differences in cost and health outcomes between Medicare patients with OA who undergo TKA and those who avoid the procedure. The Medicare 5% sample was used to identify patients diagnosed with OA during 1997-2009.

Factors that influence provider selection for elective total joint arthroplasty.

Background: The growth of consumer-directed health plans has sparked increased demand for information regarding the cost and quality of healthcare services, including total joint arthroplasty (TJA). However, the factors that influence patients' choice of provider when pursuing elective orthopaedic care, such as TJA, are poorly understood.

Questions/purposes: We evaluated the factors patients consider when selecting an orthopaedic surgeon and hospital for TJA.

Cost-effectiveness analysis of primary arthroscopic stabilization versus nonoperative treatment for first-time anterior glenohumeral dislocations.

Purpose: The purpose of this study was to compare the cost-effectiveness of initial observation versus surgery for first-time anterior shoulder dislocation.

Methods: The clinical scenario of first-time anterior glenohumeral dislocation was simulated using a Markov model (where variables change over time depending on previous states). Nonoperative outcomes include success (no recurrence) and recurrence; surgical outcomes include success, recurrence, and complications of infection or stiffness.

Brief history of quality movement in US healthcare.

The current healthcare quality improvement infrastructure is a product of a century long experience of cumulative efforts. It began with an acknowledgement of the role of quality in healthcare, and gradually evolved to encompass the prioritization of quality improvement and the development of systems to monitor, quantify, and incentivize quality improvement in healthcare. We review the origins and the evolution of the US healthcare quality movement, identify existing initiatives specific to musculoskeletal care, outline significant challenges and opportunities, and propose recommendations for the future.

Variability in costs associated with total hip and knee replacement implants.

Background: Implant costs associated with total hip replacement and total knee replacement procedures account for a large share of total costs and reimbursements to hospitals. Federal policymakers are promoting episode-of-care payment and other value-based delivery and payment reforms in part to encourage physicians and hospitals to cooperate in managing costs for these and other procedures. The present study quantifies the patient, hospital, and market characteristics associated with variation in implant and total procedure costs for hip and knee arthroplasty.

Modern metal-on-metal hip implants.

This Technology Overview was prepared using systematic review methodology and summarizes the findings of studies published as of July 15, 2011, on modern metal-on-metal hip implants. Analyses conducted on outcomes by two joint registries indicate that patients who receive metal-on-metal total hip arthroplasty (THA) and hip resurfacing are at greater risk for revision than are patients who receive THA using a different bearing surface combination. Data from these registries also indicate that larger femoral head components have higher revision rates and risk of revision and that older age is associated with increased revision risks of large-head metal-on-metal THA.

Comparative effectiveness of metal-on-metal and metal-on-polyethylene bearings in Medicare total hip arthroplasty patients.

The purpose of this study was to compare the risk of complication and revision total hip arthroplasty (THA) in Medicare THA patients with different bearings. Using the 100% Medicare database (2005-2009), the adjusted risk of complication and revision THA was calculated for 148,827 THA patients (93,929 metal-on-polyethylene, 49,646 metal-on-metal, 5252 ceramic-on ceramic). Adjusted risk of deep vein thrombosis, dislocation, periprosthetic joint infection (PJI), mechanical loosening, periprosthetic fracture, and revision THA at up to 4 years postoperatively was compared using Cox regression.

Failure of irrigation and débridement for early postoperative periprosthetic infection.

Background: Irrigation and débridement (I&D) of periprosthetic infection (PPI) is associated with infection control ranging from 16% to 47%. Mitigating factors include organism type, host factors, and timing of intervention. While the influence of organism type and host factors has been clarified, the timing of intervention remains unclear.

Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients.

Background: The patient-related risk factors for periprosthetic joint infection and postoperative mortality in elderly patients undergoing total hip arthroplasty are poorly understood. The purpose of this study was to identify the specific patient comorbidities that are associated with an increased risk of periprosthetic joint infection and of ninety-day postoperative mortality in U.S.