American Society Of Anesthesiologists Score Research Articles

Observed Differences in Patient Comorbidities and Complications Undergoing Primary Total Joint Arthroplasty Between Non-orthopaedic and Orthopaedic Referral Patients.

Value-based total joint arthroplasty (TJA) has resulted in decreasing surgeon reimbursement which has created concern that surgeons are being incentivized to avoid medically complex patients. The purpose of this study was to determine if patients who underwent primary total knee (TKA) and total hip arthroplasty (THA) had different comorbidities and complication rates based on referral type: 1) non-orthopaedic referral (NOR), 2) outside orthopaedic referral (OOR) or 3) self-referral (SR). At a single tertiary care centre, patients undergoing primary TJA between July 2019 and January 2020 were identified using current procedural codes. Data were abstracted from the Institutional National Surgical Quality Improvement Program (NSQIP) along with electronic medical records which included referral type, primary insurance, demographics, comorbidities, and comorbidity scores, including an American Society of Anesthesiology (ASA) score. Complications and outcomes were tracked for 90 days post-operatively. Referral groups were compared using Chi-square exact tests for categorical variables and t-tests or Wilcoxon Rank Sum tests for continuous variables, as appropriate. Of the 393 patients included in this study, there were 249 (63%) NOR, 104 (26%) OOR, and 40 (10%) SR. The OOR versus NOR group had a significantly greater proportion of patients with obesity (79 vs 64%, p=0.047) and an ASA score ≥3 (59 vs 43%, p=0.007). There was a significantly greater proportion of patients with wound complications (10 vs 4%, p=0.023) and ≥2 complications (14 vs 3%, p<0.001) in OOR versus NOR, respectively. Patients who underwent primary TJA and were referred by an orthopaedic surgeon tended to have more comorbid conditions and higher rates of severe complications. The observed difference in referrals may be explained by monetary incentivization in the context of current reimbursement trends. Organizations utilizing bundled payment programs to reimburse surgeons should use a risk-stratification model to mitigate incentivizing surgeons to avoid medically complex patients.

Supervised machine learning to predict non-home discharge following surgical treatment of pelvic fractures

Background: Decision-tree-based machine learning (ML) algorithms such as random forest (RF) are useful for their ability to predict outcomes and rank variables according to their utility in the decision-making process. This study utilizes RF to identify important predictors of discharge to facility following surgical stabilization of pelvis fractures, a traumatic injury that often precludes mortality and diminished quality of life. Methods: The American College of Surgeons national surgical quality improvement program (ACS-NSQIP) database was queried for patients aged 16 to 70 undergoing surgical fixation of pelvis fractures between 2008 and 2018. Outcome of interest was discharge home versus to facility. RF was trained with surgical variables, comorbidities, and other patient factors and tasked with predicting discharge location. Permutation feature importance (PFI) was then generated to identify important variables. Results: Out of 492 patients, 184 patients were discharged to facility, and 308 patients were discharged home. RF identified age, American Society of Anesthesiologists (ASA) classification, and preoperative hematocrit as top predictors for discharge to facility. Patients being discharged home were younger, had lower ASA scores, and had higher preoperative hematocrit. Conclusions: RF identified age, ASA classification, and preoperative hematocrit as top predictors for discharge destination following pelvic surgery. Knowledge of the impact of these variables can inform preoperative planning for both patients and their care team, while highlighting the opportunity to address preoperative hematocrit to both reduce cost and improve quality of care.

Analysis of the Short-Term Complications of Laparoscopic Pancreaticoduodenectomy in Patients with Metabolic Syndrome.

Objective: To investigate the impact of metabolic syndrome (MetS) on short-term complications of laparoscopic pancreaticoduodenectomy (LPD). Materials and Methods: We retrospectively analyzed perioperative data of patients who underwent LPD in our department from January 2020 to January 2022. The patients were divided into the MetS group and non-MetS group based on whether they had MetS. The incidence of postoperative complications and mortality rate was compared between the two groups. Results: The study involved 279 patients, with 30 having MetS and 249 without. However, the MetS and non-MetS groups differed significantly in terms of postoperative pancreatic fistula rate (26.6% versus 8.4%), abdominal infection rate (33.3% versus 10.0%), pulmonary complications rate (16.7% versus 6.42%), Clavien-Dindo ≥3 rate (20% versus 8.0%), multiple complications rate (23.3% versus 9.6%), percutaneous drainage rate (33.3% versus 10.0%), 90-day mortality rate (6.7% versus 1.2%), and length of postoperative hospital stay (15.00 ± 12.78 versus 10.63 ± 5.23 days). However, the two groups differed no significantly with respect to age, gender, American Society of Anesthesiologists score, preoperative CA125/CA199 levels, surgery time, specimen removal time, and intraoperative blood loss. Conclusion: MetS increases the incidence of postoperative complications and perioperative mortality rate in LPD.

Is It Getting More Expensive to Treat Patients Who Have a High Comorbidity Burden? Financial Trends in Total Knee Arthroplasty From 2013 to 2021

BackgroundUtilization of total knee arthroplasty (TKA) continues to rise among patients who have a high comorbidity burden (HCB). With changes in reimbursement models over the past decade, it is essential to assess the financial impact of HCB TKA on healthcare systems. This study aimed to examine trends in revenue and costs associated with TKA in HCB patients over time. MethodsOf 14,978 TKA performed at a large, urban academic medical center between 2013 and 2021, we retrospectively analyzed HCB patients (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores of 3 or 4). A total of 1,156 HCB TKA patients who had complete financial data were identified. Patient demographics, perioperative data, revenue, costs, and contribution margin were collected for each patient. Changes in these financial values over time, as a percentage of 2013 values, were analyzed. Linear regression was performed with a trend analysis to determine significance. ResultsFrom 2013 to 2021, the percentage of HCB TKAs per year increased from 4.2% in 2013 to 16.5% in 2021 (P < .001). The revenue of TKA in HCB patients remained steady (P = .093), while direct costs increased significantly (32.0%; P = .015), resulting in a decline of contribution margin to a low of 82.3% of 2013 margins. There was no significant change in rates of 90-day complications or home discharge following HCB TKA during the study period. ConclusionsThe results of this study indicate a major rise in cost for TKA among HCB patients, without a corresponding rise in revenue. As more patients who have HCB become candidates for TKA, the negative financial impact on institutions should be considered, as payments to institutions do not adequately reflect patient complexity. A re-evaluation of institutional payments for medically complex TKA patients is warranted to maintain patient access among at-need populations.

Early laparoscopic cholecystectomy in severely comorbid patients with acute cholecystitis: results of a monocentric study.

Aim: The aim is to evaluate laparoscopic cholecystectomy safety based on American Society of Anesthesiologists score for acute cholecystitis in patients with comorbidities. Patients & methods: This is retrospective study of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2003 and 2021. According to their respective ASA-score, patients were divided into group 1: ASA1-2 and group 2: ASA3-4. Results: We collected 578 patients. Even though the gangrenous forms were more frequent and the operative time was longer in group 2, laparoscopic cholecystectomy seems safe and effective. We didn't observe any differences in terms of intraoperative incidents, open conversion rate, or postoperative complications compared with other patients. Conclusion: ASA3-4 patients with acute cholecystitis don't face elevated risks of complications or mortality during laparoscopic cholecystectomy.

Prosthetic outcomes after amputation and the impact of mobility level on survival

ObjectiveLower extremity amputation continues to be necessary in a significant number of patients with peripheral vascular disease. The 5-year survival following lower limb loss is markedly reduced. Many of these patients are never fitted with a prosthesis, and there is a dearth of knowledge regarding the barriers to prosthetic attainment. The goal of this study was to identify the risk factors for not receiving a prosthesis and the effect of mobility level on survival following major amputation. MethodsThis was a retrospective analysis of all patients that underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to December 31, 2019. Abstracted data included: age, sex, race, body mass index, comorbidities, American Society of Anesthesiologists score, statin use, level of amputation, stump revision, fitting for prosthesis, type of prosthesis, and the United States’ Medicare Functional Classification Level, also called K level. Survival was determined using a combination of sources, including the Social Security Death Master File, searches of multiple genealogic registries, and general internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis attainment. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality. ResultsA total of 464 patients were included in this study. The mean age was 65 years, and mean body mass index was 27 kg/m2. The majority of patients were male (68%), White (56%), diabetic (62%), and hypertensive (76%), and underwent below-the-knee amputation (69%). Prosthetic attainment occurred in 185 (40%). On multivariable analysis, age >81 years and current tobacco use were associated with no prosthetic fitting. Overall 5-year survival was 41.9% (95% confidence interval [CI], 37.6%-46.6%) (below-the-knee amputation, 47.7% [95% CI, 42.5%-53.5%]; above-the-knee amputation, 28.7% [95% CI, 22.1%-37.2%]). On multivariable analysis, age >60 years, congestive heart failure, above-the-knee amputation, and no prosthetic attainment were associated with decreased survival. Increasing K level was incrementally associated with improved survival. ConclusionsThis study has identified several patient factors associated with prosthetic attainment, as well as multiple factors predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. The Medicare Functional Classification Level K level predicts survival. More research is needed to determine the barriers to prosthetic attainment and if improving a patients K level will improve survival.

Evaluating the accuracy of ChatGPT-4 in predicting ASA scores: A prospective multicentric study ChatGPT-4 in ASA score prediction

BackgroundThis study investigates the potential of ChatGPT-4, developed by OpenAI, in enhancing medical decision-making processes, particularly in preoperative assessments using the American Society of Anesthesiologists (ASA) scoring system. The ASA score, a critical tool in evaluating patients' health status and anesthesia risks before surgery, categorizes patients from I to VI based on their overall health and risk factors. Despite its widespread use, determining accurate ASA scores remains a subjective process that may benefit from AI-supported assessments. This research aims to evaluate ChatGPT-4's capability to predict ASA scores accurately compared to expert anesthesiologists' assessments. MethodsIn this prospective multicentric study, ethical board approval was obtained, and the study was registered with clinicaltrials.gov (NCT06321445). We included 2851 patients from anesthesiology outpatient clinics, spanning neonates to all age groups and genders, with ASA scores between I-IV. Exclusion criteria were set for ASA V and VI scores, emergency operations, and insufficient information for ASA score determination. Data on patients' demographics, health conditions, and ASA scores by anesthesiologists were collected and anonymized. ChatGPT-4 was then tasked with assigning ASA scores based on the standardized patient data. ResultsOur results indicate a high level of concordance between ChatGPT-4 predictions and anesthesiologists' evaluations, with Cohen's kappa analysis showing a kappa value of 0.858 (p = 0.000). While the model demonstrated over 90% accuracy in predicting ASA scores I to III, it showed a notable variance in ASA IV scores, suggesting a potential limitation in assessing patients with more complex health conditions. DiscussionThe findings suggest that ChatGPT-4 can significantly contribute to the medical field by supporting anesthesiologists in preoperative assessments. This study not only demonstrates ChatGPT-4's efficacy in medical data analysis and decision-making but also opens new avenues for AI applications in healthcare, particularly in enhancing patient safety and optimizing surgical outcomes. Further research is needed to refine AI models for complex case assessments and integrate them seamlessly into clinical workflows.

Frequency of Readmission Among American Society of Anesthesia Classification after Total Hip and Total Knee Arthroplasty

Background: With the aging population and the increasing prevalence of degenerative joint diseases, the need for total joint arthroplasty (TJA) has surged. The American Society of Anesthesiologists (ASA) Physical Status Classification System plays a pivotal role in preoperative evaluation, predicting the risk of postoperative complications and mortality. Understanding the impact of ASA classification on surgical outcomes can guide improvements in patient care and surgical planning. Objective: This study aimed to investigate the relationship between ASA classification and the risk of postoperative readmission in patients undergoing total joint arthroplasty. Methods: Conducted at a single urban medical center, this descriptive, non-randomized study involved 352 patients who underwent primary TJA due to osteoarthritis, rheumatoid arthritis, or avascular necrosis. Participants were assigned an ASA classification preoperatively. The primary outcome measured was readmission within three months post-surgery, with secondary outcomes including the incidence of complications such as deep vein thrombosis (DVT), pulmonary embolism, and surgical site infections. Data were analyzed using SPSS version 21, with significance set at p&lt;0.05. Results: Of the 352 participants, 165 (46.9%) were from rural areas, and 187 (53.1%) were from urban locations. The readmission rate was 6.8%, with ASA III and IV classifications showing significantly higher readmission rates (9.7% and 28.6%, respectively) compared to ASA I and II (1.8% and 4.4%). The most common reasons for readmission were chest infections (37.5%), followed by cardiac complications, pulmonary embolism, and neurological complications (20.8% each). The study found a significant correlation between higher ASA classification and increased readmission risk (p=0.021). Conclusion: Higher ASA classifications are associated with a greater risk of postoperative readmission in patients undergoing total joint arthroplasty. These findings underscore the importance of comprehensive preoperative assessments and tailored postoperative care strategies to mitigate the risk of readmission, particularly in patients with higher ASA scores.

Risk factors of anastomotic leak in colorectal cancer: a multicentric study in a Latin American country.

The anastomotic leak (AL) is one of the most feared complications of colorectal surgery, since it is associated with a high rate of morbidity, mortality, length of hospital stay and cost of care. Our aim was to determine the risk factors associated with anastomosis leak in colorectal cancer patients who underwent surgical resection with anastomosis. A multicentre observational, analytical, retrospective and case-control study was carried out. For each case, two controls were included from three national hospitals from Lima, Peru during the period 2021-2022. To determine the degree of association, multivariate logistic regression model was carried out. A total of 360 patients were included, 120 from each hospital. The mean age of the population was 68.03 ± 14.21 years old. The majority were 65 years old or older (66.1%), 52.8% were female, and 63.3% had clinical stage III. The 40% of the patients had albumin levels lower than 3.5 g/dL. Regarding the surgery, 96.4% were elective, 68.9% underwent open approach, and 80.8% had an operative time of more than 180 minutes. Most of them had right colon cancer (50.8%). In the multivariate analysis, a significant association was found with the age variable (OR = 2.48; 95%CI:1.24-4.97), clinical tumour level (OR = 2.71; 95%CI:1.34-5.48), American Society of Anesthesiologists (ASA) Score (OR = 3.23; 95%CI:1.10-9.50), preoperative serum albumin (OR = 22.2; 95%CI:11.5-42.9). The most important independent risk factors associated with AL among patients with colorectal cancer were pre-operative such as lower preoperative serum albumin levels, followed by a higher ASA Score, clinical-stage III-IV, and an age ≥65 years old.

Laparoscopic ventral mesh rectopexy in the oldest old is safe: the race is run.

Laparoscopic ventral mesh rectopexy (LVMR) is considered to be the gold standard for managing rectal prolapse. Nevertheless, concerns have been expressed about the use of this procedure in elderly patients. The aim of the current study was to examine the perioperative safety of primary LVMR operations in the oldest old in comparison to younger individuals and to assess our hospital policy of offering LVMR to all patients, regardless of age and morbidity. A retrospective study analysed demographic information, operation notes, meshes utilised, operation times, lengths of hospital stay (LOS) and American Society of Anesthesiologists (ASA) scores of patients who underwent LVMR at Elisabeth-TweeSteden Hospital between 2012 and 2023. Eighty-seven female patients underwent LVMR. Nineteen patients were 80years of age or older (OLD group); the remaining 65 patients were under the age of 80 (YOUNG group). The difference between the groups in terms of age was statistically significant. ASA scores were not significantly different. No mortality was observed. There was no statistically significant difference between the groups in terms of LOS, operation time or morbidity. Moreover, the postoperative morbidity profile was excellent in both groups. LVMR seems to be a safe operation for the "oldest old" patients with comorbidity, despite a single-centre, retrospective trial with limited follow-up. The present study suggests abandoning the dogma that "frail patients with rectal prolapse are not suitable for laparoscopic ventral mesh rectopexy."

Preoperative risk factors and cumulative incidence of temporary ileostomy non-closure after sphincter-preserving surgery for rectal cancer: a meta-analysis

BackgroundTemporary ileostomy (TI) has proven effective in reducing the severity of anastomotic leakage after rectal cancer surgery; however, some ileostomies fail to reverse over time, leading to conversion into a permanent stoma (PS). In this study, we aimed to investigate the preoperative risk factors and cumulative incidence of TI non-closure after sphincter-preserving surgery for rectal cancer.Materials and methodsWe conducted a meta-analysis after searching the Embase, Web of Science, PubMed, and MEDLINE databases from their inception until November 2023. We collected all published studies on the risk factors related to TI non-closure after sphincter-preserving surgery for rectal cancer.ResultsA total of 1610 studies were retrieved, and 13 studies were included for meta-analysis, comprising 3026 patients. The results of the meta-analysis showed that the identified risk factors included older age (p = 0.03), especially > 65 years of age (p = 0.03), male sex (p = 0.009), American Society of Anesthesiologists score ≥ 3 (p = 0.004), comorbidity (p = 0.001), and distant metastasis (p < 0.001). Body mass index, preoperative hemoglobin, preoperative albumin, preoperative carcinoma embryonic antigen, tumor location, neoadjuvant chemoradiotherapy, smoking, history of abdominal surgery, and open surgery did not significantly change the risk of TI non-closure.ConclusionWe identified five preoperative risk factors for TI non-closure after sphincter-preserving surgery for rectal cancer. This information enables surgeons to identify high-risk groups before surgery, inform patients about the possibility of PS in advance, and consider performing protective colostomy or Hartmann surgery.

Discharge to a Skilled Nursing Facility After Hip Fracture Results in Higher Rates of Periprosthetic Joint Infection

BackgroundFemoral neck fractures (FNFs) in elderly patients are associated with major morbidity and mortality. The influence of postoperative discharge location on recovery and outcomes after arthroplasty for hip fractures is not well understood. MethodsA multisite retrospective cohort from 9 academic centers identified patients who had FNF treated with hemiarthroplasty or total hip arthroplasty between 2010 and 2019. Patients who had diagnoses of dementia, stroke, age > 80 years, or high energy fracture were excluded. Discharge location was identified, including home-based health services (HHS), inpatient rehabilitation (IPR), or a skilled nursing facility (SNF). Rates of reoperation, periprosthetic joint infection (PJI), and mortality were compared between cohorts. Multivariate logistic regressions were performed, adjusting for age, American Society of Anesthesiologists (ASA) score, body mass index, sex, and tobacco use. Statistical significance was defined as P < .05. ResultsA total of 672 patients (315 HHS, 144 IPR, and 213 SNF) were included in this study. The average follow-up was 30 months. The SNF cohort was significantly older (P < .0001) with higher ASA scores (P < .0001) than the HHS cohort. In a logistic regression model adjusting for age, ASA score, and body mass index, the SNF cohort had higher mortality rates than the HHS cohort (P = .0296) and were more likely to have PJI within 90 days (odds ratio = 4.55, 95% confidence interval = 1.40, 4.74) and within 1 year (odds ratio = 3.08, 95% confidence interval = 1.08, 8.78). Time to PJI was significantly shorter in the SNF cohort (SNF 38 versus HHS 231 days, P = .0155). No differences were seen in dislocation or reoperation rates between the SNF and HHS cohorts. No differences were seen in complication rates between the IPR and HHS cohorts. ConclusionsDischarge to a SNF after arthroplasty for FNF is associated with increased mortality and higher rates of PJI. Hip fracture care pathways that uniformly discharge patients to SNFs may need to be re-evaluated, and surgeons should consider discharge to home with HHS when possible.

Correlation between spleen density and prognostic outcomes in patients with colorectal cancer after curative resection

ObjectiveThe objective of this study was to investigate the correlation between spleen density and the prognostic outcomes of patients who underwent curative resection for colorectal cancer (CRC).MethodsThe clinical data of patients who were diagnosed with CRC and underwent radical resection were retrospectively analyzed. Spleen density was determined using computed tomography. Analysis of spleen density in relation to overall survival (OS) and disease-free survival (DFS) utilizing the Kaplan–Meier method. Univariate and multivariate Cox regression models were used to screen for independent prognostic factors, and a nomogram was constructed to predict OS and DFS. Moreover, internally validated using a bootstrap resamplling method.ResultsTwo hundred twelve patients were included, of whom 23 (10.85%) were defined as having a diffuse reduction of spleen density (DROSD) based on diagnostic cutoff values (spleen density≦37.00HU). Kaplan–Meier analysis indicated that patients with DROSD had worse OS and DFS than those non-DROSD (P < 0.05). Multivariate Cox regression analysis revealed that DROSD, carbohydrate antigen 199 (CA199) > 37 U/mL, tumor node metastasis (TNM) stage III-IV, laparoscopy-assisted operation and American Society of Anesthesiology (ASA) score were independent risk factors for 3-year DFS. DROSD, CA199 > 37 U/mL, TNM stage III-IV, hypoalbuminemia, laparoscopy-assisted operation and ASA score were chosen as predictors of for 3-year OS. Nomograms showed satisfactory accuracy in predicting OS and DFS using calibration curves, decision curve analysis and bootstrap resamplling method.ConclusionPatients with DROSD who underwent curative resection have worse 3-year DFS and OS. The nomogram demonstrated good performance, particularly in predicting 3-year DFS with a net clinical benefit superior to well-established risk calculator.

Do Patients With Mental Illness Undergoing Office-Based Sedation Require an Increased Propofol Dosage?

Providers report needing higher sedative doses to achieve adequate sedation in patients with mental illnesses. These claims, however, have not been thoroughly assessed. The purpose of the study was to measure the association between mental illness and the propofol dosage necessary to achieve a satisfactory level of anesthesia. The study consisted of a single-center, retrospective cohort consisting of patients treated by oral and maxillofacial surgery at the University of Cincinnati Medical Center in 2020. The study was comprised of subjects 15 or older who were American Society of Anesthesiologists (ASA) classification I or II. Subjects under 15 or ASA III or higher were excluded from the study. The predictor variable was the presence or absence of mental illness. The primary outcome was the total dose of propofol, measured as the total amount of propofol administered divided by the patient's weight in kilograms divided by the length of the procedure in minutes (mg/kg/min). The secondary outcome was the Richmond Agitation-Sedation Scale (RASS) score achieved during sedation. Sex, race, ethnicity, age, weight, body mass index, ASA score, prior tobacco use, marijuana use, use of adjunct midazolam, fentanyl, and ketamine during the procedure, and type of procedure served as covariates. Test statistics were calculated using the Wilcoxon rank-sum test, Kruskal-Wallis test, Spearman rank correlation test, and χ2 test for bivariate analyses. Linear and logistic regression models were used to estimate association while controlling for confounding. P values ≤ .05 were considered statistically significant. The study sample was 409 subjects (36.92% male, mean age 28.27±12.20years). In bivariate analysis, mental illness did not show any association with propofol dose (mean dose with mental illness 150.85±143.97mg/kg/min, mean dose without mental illness 116.54±104.16, P=.08) or RASS score (sufficiently sedated with mental illness 63.38%, sufficiently sedated without mental illness 58.80%, P=.36). After adjusting for all previously mentioned covariates, mental illness was statistically associated with propofol dose (P<.01). Adjusting for covariates, only sex had a statistically significant association with the RASS score (P<.05). The findings suggest that a patient's mental illness may influence the amount of sedative required to achieve satisfactory anesthesia.

A comparative analysis of Charlson's weighted index of comorbidity and perforated peptic ulcer scores in predicting postoperative mortality and high comprehensive complication index.

Limited data exists on Charlson's weighted index of comorbidity (WIC) predictability for postoperative outcomes following perforated peptic ulcer (PPU) surgery. This study assesses the utility of WIC and other predictive scores in forecasting both postoperative mortality and morbidity in PPU. Patients with PPUs operated between 2018 and 2021 in a Malaysian tertiary referral center were included. Clinical data were retrospectively analyzed for association with mortality and morbidity measured with the Comprehensive Complication Index (CCI). Predictability of WIC and other predictors were examined using area under receiver-operator characteristic (ROC) curve (AUC). Among 110 patients included, 18 died (16.4%) and 36 (32.7%) had significant morbidity postoperatively (High CCI, ≥26.2). Both mortality and high CCI were associated with age >65years, female sex, comorbidities (diabetes mellitus, hypertension, and renal disease), and American Society of Anesthesiologist score >2. Most patients who died had renal dysfunction, metabolic acidosis, lactate >2mmol/L upon presentation preoperatively. While surgery >24h after presentation correlated with mortality and high CCI, the benefit of earlier surgery <6h or <12h was not demonstrated. WIC (AUC, 0.89; 95% CI, 0.81-0.99) showed similar predictability to Peptic Ulcer Perforation (PULP) (AUC, 0.97; 95% CI, 0.93-1.00) for mortality. PULP effectively predicted high CCI (AUC, 0.83; 95% CI, 0.73-0.93; p<0.001). WIC is valuable in predicting mortality, highlighting the importance of comorbidity in risk assessment. PULP score was effective in predicting both mortality and high CCI. Early identification of patients with high perioperative risk will facilitate patients' triage for escalated care, leading to a better outcome.

Safety of Same-Day Discharge Following Total Ankle Arthroplasty: A Retrospective Cohort Analysis.

Joint replacement procedures have traditionally been performed in an inpatient setting to minimize complication rates. There is growing evidence that total ankle arthroplasty (TAA) can safely be performed as an outpatient procedure, with the potential benefits of decreased health care expenses and improved patient satisfaction. Prior studies have not reliably made a distinction between outpatient TAA defined as length of stay <1 day and same-day discharge. The purpose of our study was to compare a large volume of same-day discharge and inpatient TAA for safety and efficacy. Patients undergoing TAA at our US-based institution are part of an institutional review board-approved registry. We queried the registry for TAA performed by the single highest-volume surgeon at our institution between May 2020 and March 2022. Same-day discharge TAA was defined as discharge on the day of the procedure. Patient demographics, baseline clinical variables, concomitant procedures, postoperative complications, and patient-reported outcomes were collected. Postoperative outcomes were compared after 1:1 nearest-neighbor matching by age, sex, Charlson Comorbidity Index (CCI), and American Society of Anesthesiologists (ASA) score. Multivariable models were created for comparison with the matched cohort outcome comparison analysis. Our same-day discharge group was younger (median 58 vs 67 years; P < .001), with proportionally fewer females (36.4% vs 51.4%; P = .044) and lower Charlson Comorbidity Indices (median 1 vs 3; P < .001) than the inpatient group. At a median follow-up of 1 year, after matching by age, sex, CCI, and ASA score, there was no difference in complications (P = .788), reoperations (P = .999), revisions (P = .118), or Patient-Reported Outcomes Measurement Information System (PROMIS) scores between the 2 groups. Multivariable analyses performed demonstrated no evidence of association between undergoing same-day discharge TAA vs inpatient TAA and reoperation, revision, complication, or 1-year PROMIS scores (P > .05). In our system of health care, with appropriate patient selection, same-day discharge following TAA can be a safe alternative to inpatient TAA. Level III, retrospective cohort study.

Ten Year Experience With Same Day Discharge Outpatient Total Hip Arthroplasty: Patient Demographics Changed, but Safe Outcomes Were Maintained

BackgroundThis study aimed to characterize changes in patient demographics and outcomes for same-day discharge total hip arthroplasty (THA) over a 10-year period at a single orthopaedic specialty hospital. MethodsA consecutive series of 1,654 patients between 2013 and 2022 who underwent unilateral THA and were discharged on the same calendar day were retrospectively reviewed. Patient demographics, including age, sex, body mass index (BMI), age-adjusted Charlson Comorbidity Index, and American Society of Anesthesiologists (ASA), were collected. Readmissions, complications, and unplanned visits were recorded for 90 days postoperatively. In order to compare the demographics of patients over time, patients were divided into 3 groups: Time Group A (2013 to 2016), Time Group B (2017 to 2019), and Time Group C (2020 to 2022). ResultsThe mean age, BMI, ASA score, and CCI increased significantly across each time group. Age increased from 57 years (range, 23 to 77) to 60 years (range, 20 to 87). The BMI increased from 28.1 (range, 18 to 41) to 29.4 (range, 18 to 47). The percentage of patients aged > 70 years almost doubled over time, as did the percentage of patients who had a BMI > 35. Overall complications increased from 3.44 to 6.82%, reflective of the changing health status of patients. Readmissions increased from 0.57 to 1.70% over time. Despite this, there were no readmissions for any patient within the first 24 hours of surgery. ConclusionsOur study has 3 important findings. We identified a worsening patient demographic over time with an increasing percentage of patients of advanced age and higher BMI, ASA, and age-adjusted Charlson Comorbidity Index. Also, there was also an increase in readmissions, complications, and unplanned visits. In addition, despite this worsening patient demographic, there were no readmissions within 24 hours and a low rate of readmissions or unplanned visits within the first 48 hours across all time periods, suggesting that same-day discharge-THA continues to be safe in properly selected patients.

Risk Factors and Characteristics of In-Hospital Falls After Spine Surgery: A Retrospective, Single-Center Cohort Study in the Republic of Korea.

Falls after orthopaedic surgery can cause serious injuries, which lengthen hospital stays and increase medical expenses. This has prompted hospitals to implement various fall-prevention protocols. The aims of this study were to determine the incidence of in-hospital falls after spine surgery, to analyze the overall risk factors, to discern factors that have a major influence on falls, and to evaluate the effectiveness of the fall-prevention protocol that we implemented. This was a retrospective, single-center study including patients who underwent spine surgery from January 2011 to November 2021 at the National Health Insurance Service Ilsan Hospital (NHISIH) in Goyang, Republic of Korea. Reported falls among these patients were examined. Patient demographics; surgery type, date, and diagnosis; and fall date and time were evaluated. Overall, 5,317 spine surgeries were performed, and 128 in-hospital falls were reported (overall incidence: 2.31%). From the multivariable analyses, older age and American Society of Anesthesiologists (ASA) score were identified as independent risk factors for in-hospital patient falls (multivariable adjusted hazard ratio [aHR] for age 70 to 79 years, 1.021 [95% confidence interval (CI), 1.01 to 1.031]; for age ≥80 years, 1.035 [1.01 to 1.06]; and for ASA score of 3, 1.02 [1.01 to 1.031]). Similar results were seen in the subgroup who underwent primary surgery. Within 2 weeks following surgery, the highest frequency of falls occurred at 3 to 7 days postoperatively. The lowest fall rate was observed in the evening (6 to 10 p.m.). Morbidities, including rib, spine, and extremity fractures, were recorded for 14 patients, but none of these patients underwent operative treatment related to the fall. The NHISIH implemented a comprehensive nursing care service in May 2015 and a fall protocol in May 2017, but the annual incidence rate did not improve. The fall rate was higher after thoracolumbar surgeries (2.47%) than after cervical surgeries (1.20%). Moreover, a higher fall rate was observed in thoracolumbar cases with a greater number of fusion levels and revision spine surgeries. Patients with advanced age, more comorbidities, a greater number of fusion levels, and revision surgeries and who are female are more vulnerable to in-hospital falls after spine surgery. Novel strategies that target these risk factors are warranted. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patient-Related Predictors of Treatment Failure After Two-Stage Total Hip Arthroplasty Revision for Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis

BackgroundPeriprosthetic joint infection (PJI) treatment has high failure rates even after 2-stage revision. Risk factors for treatment failure (TF) after staged revision for PJI are not well defined, nor is it well established how they correlate with the risks of developing an index PJI. Identifying modifiable risk factors may allow preoperative optimization, while identifying nonmodifiable risk factors can influence surgical options or advise against further surgery. We performed a systematic review and meta-analysis to better define predictors of TF in 2-stage revision for PJI. MethodsThe PubMed, Embase, and Scopus databases were searched from their inception in December 1976 to April 15, 2023. Studies comparing patient-related variables between patients successfully treated who had 2-staged revision total hip arthroplasty (THA) and patients with persistent infections were included. Studies were screened, and 2 independent reviewers extracted data, while a third resolved discrepancies. Meta-analysis was performed on these data. There were 10,052 unique studies screened, and 21 studies met the inclusion criteria for data extraction. ResultsThere was good-quality evidence that obesity, liver cirrhosis, and previous failed revisions for PJI are nonmodifiable risk factors, while intravenous drug use (IVDU) and smoking are modifiable risk factors for TF after 2-stage revision for hip PJI. Reoperation between revision stages was also significantly associated with an increased risk of TF. Interestingly, other risk factors for an index PJI including male gender, American Society of Anesthesiology score, diabetes mellitus, and inflammatory arthropathy did not predict TF. Evidence on Charlson Comorbidity Index was limited. ConclusionsPatients with a smoking history, obesity, IVDU, previous failed revision for PJI, reoperation between stages, and liver cirrhosis are more likely to experience TF after 2-stage revision THA for PJI. Modifiable risk factors include smoking and IVDU and these patients should be referred to services for cessation as early as possible before 2-stage revision THA.

Trends in Revenue, Cost, and Contribution Margin of Patients Who Have a High Comorbidity Burden Undergoing Total Hip Arthroplasty From 2013 to 2021

BackgroundWith the increasing utilization of total hip arthroplasty (THA) in patients who have a high comorbidity burden (HCB), coinciding with modifications to reimbursement models over the past decade, an evaluation of the financial impact of HCB on THA over time is warranted. This study aimed to investigate trends in revenue and cost associated with THA in HCB patients. MethodsOf 13,439 patients who had primary, elective THA between 2013 and 2021 at our institution, we retrospectively reviewed 978 patients considered to have HCB (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores 3 or 4). We collected patient demographics, perioperative data, revenue, cost, and contribution margin (CM) of the inpatient episode. We analyzed changes as a percentage of 2013 values over time for these financial markers. Linear regression determined trend significance. The final analysis included 978 HCB patients who had complete financial data. ResultsBetween 2013 and 2021, direct costs increased significantly (P = .002), along with a nonsignificant increase in total costs (P = .056). While revenue remained steady during the study period (P = .486), the CM decreased markedly to 38.0% of 2013 values, although not statistically significant (P = .222). Rates of 90-day complications and home discharge remained steady throughout the study period. ConclusionsIncreasing costs for HCB patients undergoing THA were not matched by an equivalent increase in revenue, leading to dwindling CMs throughout the past decade. Re-evaluation of reimbursement models for THA that account for patients’ HCB may be necessary to preserve broad access to care. Level of EvidenceIII.