Singh, Jasvinder A

ObjectiveTo examine whether an underlying diagnosis of rheumatoid arthritis (RA) or osteoarthritis (OA) impacts the 90‐day readmission rates after total hip arthroplasty (THA) or total knee arthroplasty (TKA).MethodsWe analyzed prospectively collected data from an integrated health care system, Total Joint Replacement Registry, of adults with RA or OA undergoing unilateral primary THA or TKA during 2009–2011. Adjusted logistic regression models for 90‐day readmission were fit. Odds ratios with 95% confidence intervals (95% CIs) were calculated. Study year was an effect modifier for the outcome; therefore separate analyses were conducted for each of the 3 study years.ResultsOf the 34,311 patients, 496 had RA and 33,815 had OA. Comparisons of RA and OA patients, respectively, were 73% and 61% women, 45% and 70% white, and patients had a mean age of 61 versus 67 years (P < 0.001). Crude 90‐day readmission rates for RA and OA were 8.5% and 6.7%, respectively. The adjusted odds of 90‐day readmission increased from year to year for RA compared to OA patients, from 0.89 (95% CI 0.46–1.71) in 2009 to 1.34 (95% CI 0.69–2.61) in 2010, and to 1.74 (95% CI 1.16–2.60) in 2011. The 2 most common readmission reasons were joint prosthesis infection (10.2%) and septicemia (10.2%) in RA and joint prosthesis infection (5.7%) and other postoperative infection (5.1%) in OA.ConclusionRA is a risk factor for 90‐day readmission after primary THA or TKA. An increasing risk of readmissions noted in RA in 2011 is concerning and indicates that further studies should examine the reasons for this increasing trend.

ObjectiveTo study the time trends in sociodemographic and clinical characteristics of patients undergoing primary total knee arthroplasty (TKA).MethodsWe used the Mayo Clinic Total Joint Registry to examine the time trends in patient demographics (body mass index [BMI] and age), underlying diagnosis, medical (Deyo‐Charlson Index) and psychological comorbidity (anxiety and depression), and examination findings of primary TKA patients from 1993–2005. We used the chi‐square test and analysis of variance.ResultsIn total, 7,229 patients constituted the primary TKA cohort; 55% were women. The mean age decreased by 1.3 years (69.3 to 68.0 years), mean BMI increased by 1.7 kg/m2 (30.1 to 31.8 kg/m2), and mean Deyo‐Charlson Index increased by 36% (1.1 to 1.5) over the 13‐year study period (P ≤ 0.001 for all). Compared with 1993–1995, significantly more patients (by 2–3 times) in 2002–2005 had a BMI ≥40 kg/m2 (4.8% versus 10.6%), age <50 years (2.9% versus 5.2%), Deyo‐Charlson Index of ≥3 (12% versus 22.3%), depression (4.1% versus 14.8%), and anxiety (4.1% versus 8.9%), and significantly fewer patients had an underlying diagnosis of rheumatoid/inflammatory arthritis (6.4% versus 1.5%; P < 0.001 for all). Compared with 1993–1995, significant reductions were noted in 2002–2005 for the physical examination findings of anteroposterior knee instability, mediolateral knee instability, moderate to severe knee synovitis, severe limp, fair or poor muscle strength, and absent peripheral pulses (P ≤ 0.001 for all).ConclusionIn this large US total joint registry study, we found significant time trends in patient characteristics, diagnosis, comorbidity, and knee/extremity examination findings in primary TKA patients over 13 years. These secular trends should be taken into account when comparing outcomes over time and in policy‐making decisions.

ObjectiveTo determine the association of the underlying diagnosis with limitation in activities of daily living (ADL) and pain in patients undergoing primary total knee arthroplasty (TKA).MethodsProspectively collected data from the Mayo Clinic Total Joint Registry were used to assess the association of diagnosis with moderate–severe limitation in ADL and moderate–severe pain at 2 and 5 years after primary TKA, using multivariable‐adjusted logistic regression analyses. We calculated odds ratios (ORs) and 95% confidence intervals (95% CIs).ResultsThere were 7,139 primary TKAs at 2 years and 4,234 at 5 years. In multivariable‐adjusted analyses, compared with rheumatoid arthritis (RA)/inflammatory arthritis, osteoarthritis (OA) was associated with significantly lower moderate–severe ADL limitation at 2 years (OR 0.5 [95% CI 0.3–0.8]) (P = 0.004) and at 5 years (OR 0.5 [95% CI 0.3–0.9]) (P = 0.02). There was no significant association of diagnosis of OA with moderate–severe pain at 2 years (OR 1.2 [95% CI 0.5–2.7]) (P = 0.68) or at 5 years (OR 1.0 [95% CI 0.3–3.7]) (P = 1.0).ConclusionWe found that patients with OA who underwent primary TKA had better ADL outcomes compared to patients with RA/inflammatory arthritis at 2 and 5 years. On the other hand, the pain outcomes after primary TKA did not differ in OA versus RA. This suggests a discordant effect of underlying diagnosis on pain and function outcomes after TKA. These novel findings can be used to better inform both patients and surgeons about expected pain and function outcomes after primary TKA.

Objective To assess the mediation of smoking-associated postoperative mortality by postoperative complications. Design Observational cohort study. Setting Using data from the Veterans Affairs (VA) Surgical Quality Improvement Programme, a quality assurance programme for major surgical procedures in the VA healthcare system, we assessed the association of current smoking at the time of the surgery with 6-month and 1-year mortality. Primary and secondary outcome measures Using mediation analyses, we calculated the relative contribution of each smoking-associated complication to smoking-associated postoperative mortality, both unadjusted and adjusted for age, race/ethnicity, work relative value unit of the operation, surgeon specialty, American Society of Anesthesiologists class and year of surgery. Smoking-associated complications included surgical site infection (SSI), cardiovascular complications (myocardial infarction, cardiac arrest and/or stroke) and pulmonary complications (pneumonia, failure to wean and/or reintubation). Results There were 186 632 never smokers and 135 741 current smokers. The association of smoking and mortality was mediated by smoking-related complications with varying effects. In unadjusted analyses, the proportions of mediation of smoking to 6-month mortality explained by the complications were as follows: SSIs 22%, cardiovascular complications 12% and pulmonary complications 89%. In adjusted analyses, the per cents mediated by each complication were as follows: SSIs 2%, cardiovascular complications 4% and pulmonary complications 22%. In adjusted analyses for 1-year mortality, respective per cents mediated were 2%, 3% and 16%. Conclusions Pulmonary complications, followed by cardiovascular complications and SSIs were mediators of smoking-associated 6-month and 1-year mortality. Interventions targeting smoking cessation and prevention and early treatment of pulmonary complications has the likelihood of reducing postoperative mortality after elective surgery.

BACKGROUNDThe objective of this study was to explore relations between patient role preferences during the cancer treatment decision‐making process and quality of life (QOL).METHODSOne‐year cancer survivors completed a survey in 2000 as part of a larger survey conducted by the American Cancer Society. The current report was based on survey respondents from Minnesota (response rate, 37.4%). Standardized measures included the Profile of Mood States (scores were converted to have a range, from 0 to 100, with 100 indicating the best mood), the Medical Outcomes Survey 36‐item short‐form health survey (SF‐36) (standardized scores), and the Control Preferences Scale. Patients' actual and preferred role preference distributions and concordance between roles were compared with QOL scores using 2‐sample t test methodology.RESULTSThe actual role of survivors (n = 594) in cancer care was 33% active, 50% collaborative, and 17% passive. Their preferred role was 35% active, 53% collaborative, and 13% passive. Overall, 88% of survivors had concordant preferred and actual roles. Survivors who had concordant roles had higher SF‐36 Physical Component Scale (PCS) scores (P < .01), higher vitality (P = .01), less fatigue (P < .01), less confusion (P = .01), less anger (P = .046), and better overall mood (P = .01). These results were similar among both women and younger individuals (aged <60 years). Survivors who had active actual roles had higher PCS scores (P < .01), less tension (P = .04), and higher vitality (P = .04) than survivors who were either collaborative or passive. No differences existed in QOL scores according to preferred role.CONCLUSIONSSurvivors who experienced discordance between their actual role and their preferred role reported substantial QOL deficits in both physical and emotional domains. These results indicate the need to support patient preferences. Cancer 2013;119:2342–2349. © 2013 American Cancer Society.

ObjectiveTotal knee arthroplasty (TKA) is a widely utilized and effective treatment option for end‐stage knee osteoarthritis (OA). Knee OA is more prevalent among women compared to men, but there are limited data on the sex differences in surgical outcomes after primary TKA.MethodsOur sample consisted of all primary TKAs performed in Pennsylvania during the fiscal year 2002. We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify major complications and surgical revision. We used mixed‐effects logistic regression models to examine the associations between sex and all‐cause mortality, readmissions, and major surgical complications. We used proportional hazards models to assess the risk of surgical revision after index arthroplasty. We adjusted for race, age, hospital teaching status, hospital procedure volume, insurance status, and risk of mortality.ResultsIn 17,994 primary TKAs, there were 46 and 220 deaths at 30 days and 1 year, respectively. Compared to women, men had higher adjusted odds of 1‐year mortality (odds ratio [OR] 1.48 [95% confidence interval (95% CI) 1.13–1.94]) after primary TKA. The overall odds of most major 30‐day complications did not differ by sex except for surgical wound infections, which were higher in men compared to women (OR 1.31 [95% CI 1.08–1.60]); 30‐day readmission was higher in men (OR 1.25 [95% CI 1.10–1.43]). Men had significantly higher rates of revision of index knee arthroplasty at 5 years (hazard ratio 1.20 [95% CI 1.05–1.36]) compared to women.ConclusionThe higher rates of mortality, hospital readmissions, revision surgery, and wound infections in men undergoing elective primary TKA compared to women indicate there is a sex disparity in these outcomes.

ABSTRACTPurposeTo identify studies that have validated administrative and claims database algorithms for identifying patients with orthopedic device revision or removal.MethodsAs a part of the Food and Drug Administration's Mini‐Sentinel pilot program, we performed a systematic review to identify algorithms for orthopedic implant removal/revision in administrative and claims databases in the USA or Canada.ResultsFive studies examined the validity of database algorithms against a gold standard of documentation in medical records (n = 3) or codes/documentation in another database (n = 2). The positive predictive values (PPV) of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) and/or the Current Procedural Terminology codes for revision total hip arthroplasty (THA) in the US Medicare population compared with medical record review were 92%and 91%, respectively. In another study of the US Medicare population, multiple ICD‐9 codes for revision total knee arthroplasty were compared with newly available single ICD‐9‐CM codes for revision knee arthroplasty; sensitivity was 87% and specificity was 99% (PPV not provided). The fourth study validated the ICD‐9‐CM codes for revision total knee arthroplasty against Ontario health insurance physician fee service claims as the gold standard and found a PPV of 32%. In the last study in Medicare population, the accuracy of the attribution of revision THA to the same side as the earlier index primary THA was examined; PPV for same laterality of revision THA was 71% (using ICD‐9‐CM codes).ConclusionsValidation data, with regard to the ICD‐9‐CM or the Current Procedural Terminology code algorithms for revision THA in the Medicare population, exist. More validation studies are needed to confirm these findings and examine other large databases. Copyright © 2012 John Wiley & Sons, Ltd.