National Administrative Database Research Articles

Does Perioperative Antibiotic Administration Decrease the Incidence of Prosthetic Joint Infection in Patients Undergoing Elective Soft Tissue Hand Surgery?

The use of prophylactic antibiotics in patients with existing total hip or knee arthroplasty undergoing elective hand surgery has not been studied. We tested the null hypothesis that perioperative antibiotic administration is not associated with the incidence of prosthetic joint infection (PJI) in patients undergoing elective, soft tissue hand surgery. We used a large, national administrative claims database to identify patients with existing total hip or knee arthroplasty undergoing soft tissue hand surgery (carpal tunnel release, de Quervain release, trigger finger release, limited palmar fasciectomy, ganglion or mucoid cyst removal, or soft tissue mass removal). Antibiotic prophylaxis was defined as the same day administration of intravenous cefazolin, vancomycin, or clindamycin. Patients receiving antibiotics were propensity score-matched in a 1:1 ratio to those who did not, accounting for age, sex, geographic region, insurance plan, subsequent surgeries, and the presence of comorbid diabetes mellitus, rheumatoid arthritis, myocardial infarction, congestive heart failure, chronic kidney disease, human immunodeficiency virus infection, chronic kidney disease, malignancy, obesity, or tobacco use. Residual differences between matched cohorts were adjusted for using multivariable logistic regression. The primary outcome was the incidence of PJI within 6, 9, and 12 months after hand surgery. The overall incidence of PJI was 0.8% (166/21,582) within 12 months after hand surgery. There was no difference in the incidence of PJI between patients who received antibiotic prophylaxis and those who did not at 6 (0.3% vs 0.5%), 9 (0.6% vs 0.7%), or 12 months (0.7% vs 0.8%) after hand surgery. These findings were unchanged after adjusting for residual confounding. Surgical site infection within 3 months after hand surgery was also not associated with PJI at 6, 9, or 12 months. We found no association between prophylactic antibiotic administration in patients with prior total hip or knee arthroplasty undergoing soft tissue hand surgery and the incidence of PJI at 6, 9, and 12 months after surgery. Prognostic II.

Reverse Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Nationwide Analysis

Introduction: Reverse shoulder arthroplasty (RSA) was originally developed for treating rotator cuff arthropathy but is now commonly used for rheumatoid arthritis (RA)-related shoulder degeneration. While previous studies have identified RA to be a risk factor for complications following total shoulder arthroplasty, its specific impact on RSA outcomes remains unclear. This study aims to evaluate the post-operative medical and implant-related complications, and healthcare utilization, among RA patients undergoing RSA. Methods: A retrospective analysis of patients undergoing RSA was conducted using a national administrative claims database from 2010 to 2023. Patients who underwent RSA with and without RA were identified using corresponding diagnoses and procedural codes. Patients with RA who underwent RSA had propensity score matched to a control on a 1:5 basis. The control group consisted of patients who did not have RA and underwent RSA for any other indication. Results: A total of 7232 of RSA patients with RA were matched to 36,054 control patients. The RA cohort had significantly higher rates of 90-day medical complications when compared to the control (p < 0.001), with the highest rates in urinary tract infections (OR: 9.69), pulmonary embolisms (OR: 9.69), and the need for blood transfusions (OR:9.41). Patients with RA had significantly greater odds of developing all implant-related complications within 2 years compared to the control group (p < 0.001). This cohort also had significantly higher fall rates (p < 0.001) and mean lengths of stay (3.42 vs. 2.0 days, p < 0.0001). Conclusions: RSA patients with prior diagnoses of RA face a higher risk of implant-related and medical complications, falls, and prolonged hospital stays compared to the control. These findings suggest that RA is an independent risk factor for reverse total shoulder arthroplasty. Therefore, these patients should be closely monitored post-operatively to reduce complications, cost of care, and length of stay. Level of Evidence: III, retrospective case–control study

Recommendations for Improving Surveillance of Congenital Anomalies in Europe Using Healthcare Databases.

Although accessing administrative data in healthcare databases may be a more time-efficient and cost-effective method of conducting surveillance, there is evidence suggesting that administrative data alone are not sufficient for population-based surveillance of congenital anomalies. To propose recommendations to maximise the potential use of healthcare databases for surveillance of congenital anomalies based on our data linkage experiences and results from the EUROlinkCAT study. EUROlinkCAT is a population-based cohort study of 99,416 children with anomalies born between 1995 and 2014. The congenital anomaly case records of children in 11 European congenital anomaly (EUROCAT) registries (eight countries) were linked to standardised administrative healthcare data (birth records, death records and hospital discharge records) to evaluate mortality and morbidity outcomes in these children. Overall, 97% of children with anomalies were successfully matched to their records in their national or regional administrative databases. Recommendations to improve surveillance of anomalies when using healthcare data were developed through establishing and analysing data from this cohort. The primary recommendation is to develop systems to report anomalies diagnosed in foetuses who undergo a termination and link these data to their mothers. Each liveborn baby must be assigned a permanent unique identification number at birth to enable accurate linkage across healthcare databases. Implementing and improving existing algorithms to discriminate between major anomalies and suspected or minor anomalies will improve accuracy in coding. Heterogeneity in coding anomalies will improve by avoiding the use of 'unspecified' or 'other specified' codes in hospital databases. Relaxation of country-specific regulations concerning the suppression of small numbers are necessary to enable data to be combined across European countries. Implementation of these recommendations will enable the information in electronic healthcare databases, in conjunction with Congenital Anomaly registries, to be fully exploited and hence will improve the surveillance of anomalies in children.

Antibiotic Prescription Trends in Dentistry: A Descriptive Study Using Japan's National Database.

Antibiotic prescription trends in dentistry in Japan remain underexplored. This study aimed to describe these trends and evaluate the impact of the national antimicrobial stewardship program launched in 2016. Using Japan's national administrative claims database from fiscal year (FY) 2015 to FY 2020, this cross-sectional study comprehensively analyzed trends in antibiotic prescription by dentists. Prescription rates were computed per 1000 inhabitants yearly and standardized to the FY 2015 national population. Changes in prescription rates were evaluated using Poisson regression analysis. In FY 2020, the total number of antibiotic prescriptions was 134.4 per 1000 inhabitants per year, showing a 6% decline over the 6-year period (95% confidence interval, 6%-6%). Third-generation cephalosporins constituted 52.3% of dental antibiotic prescriptions in FY 2020, though the proportion had slightly decreased. In hospitals, prescriptions of third-generation cephalosporins decreased from 64.9% in 2015 to 20.3% in 2020, being replaced by penicillin (from 15.0% to 64.0%). However, in clinics, the magnitude of the change was small (third-generation cephalosporins, 60.5%-53.1%; penicillin, 10.2%-22.2%). Third-generation cephalosporins continue to dominate dental antibiotic prescriptions. The increase in penicillin use was much more pronounced in hospitals than in clinics. Strengthening antimicrobial stewardship, particularly in clinics where the majority of dental care is provided, is crucial.

Higher hospital volume reduces early failure rates in single-stage revision TKR for infection: An analysis of the United Kingdom National Joint Registry and National Administrative Databases.

Revision knee replacement (RevKR) for infection is rare but increasing. It is hypothesised that higher hospital volume reduces adverse outcomes. The aim was to estimate the association of surgical unit volume with outcomes following first, single-stage RevKR for infection. This population-based cohort study merged data from the United Kingdom National Joint Registry, Hospital Episode Statistics, National Patient Reported Outcome Measures and the Civil Registrations of Death. Patients undergoing procedures between 1 January 2009 and 30 June 2019 were included. Early outcomes were chosen to reflect the quality of the surgical provision and included re-revision at 2 years, mortality, serious medical complications, length of stay and patient-reported outcome measures (PROMs). Adjusted fixed effect multivariable regression models were used to examine the association between surgical unit mean annual caseload and the risk of adverse outcomes. A total of 1477 patients underwent first-time single-stage RevKRs for infection across 267 surgical units and 716 surgeons. Following adjustment for age, gender, American Society of Anaesthesiologists grade, surgeon volume, year of surgery and operation funder and modelling surgical unit volume with restricted cubic spline, a greater mean annual volume was associated with a lower risk of re-revision at 2 years. The odds of re-revision in hospitals performing fewer than or equal to 12 cases per year was 2.53 (95% confidence interval = 1.50-4.31) times more likely than hospitals performing three to four cases per month. Annual variation in surgical unit volume was not associated with mortality and serious medical complications within 90 days. Only 99 out of 1477 (7%) of patients had linked PROMs which precluded subsequent analysis. Overall, higher volume surgical units had lower rates of early re-revision following the first RevKR for infection. We were unable to provide recommended specific volume thresholds for units; however, the probability of re-revision appears to be lowest in the highest volume units. Level III, retrospective cohort study of prospectively collected data.

Trends in screening and treatment of osteoporosis after periprosthetic fractures from 2010 to 2020.

Periprosthetic fractures (PPF) typically occur from low-energy mechanisms and are pathognomonic for osteoporosis. However, osteoporosis is often underrecognized and undertreated. The aim of this study was to examine trends in dual energy X-ray absorptiometry (DXA) scans and treatment of osteoporosis after PPF between 2010 and 2020. Patients older than 40 who experienced a lower extremity PPF between 2010 and 2020 and had no prior history of osteoporosis screening or treatment were identified utilizing a large national administrative database. Rates of bone mineral density (BMD) measurement using DXA and anti-osteoporotic treatment with pharmacotherapy, or either intervention within 1year following experiencing a PPF were determined. The rate of change for these interventions was calculated using the compounded annual growth rate (CAGR), with linear regression used to determine whether trends were statistically significant. In total, 5.7% and 3.6% of patients were screened and treated for osteoporosis, respectively. Between 2010 and 2020, there was no significant change in rates of osteoporosis screening (CAGR + 0.1%; p = 0.13), treatment (CAGR - 2.4%; p = 0.29), or either intervention (CAGR - 1.1%; p = 0.77) within 1year following PPF. Factors associated with intervention included older age, female sex, and increased comorbidities. Our study found that there has been no significant change in the rates of osteoporosis screening or treatment within 1year following PPF. Orthopedic surgeons and allied healthcare workers can play an integral role in helping to curtail the osteoporosis epidemic.

Development and validation of a model to identify polycystic ovary syndrome in the French national administrative health database

BackgroundWe aimed to develop and validate an algorithm for identifying women with polycystic ovary syndrome (PCOS) in the French national health data system.MethodsUsing data from the French national health data system, we applied the International Classification of Diseases (ICD-10) related diagnoses E28.2 for PCOS among women aged 18 to 43 years in 2021. Then, we developed an algorithm to identify PCOS using combinations of clinical criteria related to specific drugs claims, biological exams, international classification of Diseases (ICD-10) related diagnoses during hospitalization, and/or registration for long-term conditions. The sensitivity, specificity and positive predictive value (PPV) of different combinations of algorithm criteria were estimated by reviewing the medical records of the Department of Reproductive Medicine at a university hospital for the year 2022, comparing potential women identified as experiencing PCOS by the algorithms with a list of clinically registered women with or without PCOS.ResultsWe identified 2,807 (0.01%) women aged 18 to 43 who received PCOS-related care in 2021 using the ICD-10 code for PCOS in the French National health database. By applying the PCOS algorithm to 349 women, the positive and negative predictive values were 0.90 (95%CI (83–95) and 0.93 (95%CI 0.90–0.96) respectively. The sensitivity of the PCOS algorithm was estimated at 0.85 (95%CI 0.77–0.91) and the specificity at 0.96 (95%CI 0.92–0.98).ConclusionThe validity of the PCOS diagnostic algorithm in women undergoing reproductive health care was acceptable. Our findings may be useful for future studies on PCOS using administrative data on a national scale, or even on an international scale given the similarity of coding in this field.

Distal Radius Fracture in the Setting of Human Immunodeficiency Virus: Management and Adverse Events.

Previous research has highlighted the elevated fracture risk among patients with human immunodeficiency virus (HIV). The current study assesses the association between HIV and the management and adverse events of distal radius fractures. Patients with a distal radius fracture from 2016 to 2022 were identified in a national administrative database. Patients were stratified by HIV status, and antiretroviral therapy (ART) use was identified. Fracture treatment modality (open or closed) was determined, and adverse events were identified within 1 year of fracture. Treatment modality and adverse events were compared using logistic regression and chi-square tests, respectively. Among 396,544 patients with a distal radius fracture, 2,392 had HIV. HIV status was not associated with treatment modality. For patients with closed treatment, those with HIV had greater rates of malunion or nonunion and wrist arthritis. For patients with open treatment, HIV was also associated with greater incidence of malunion or nonunion. When stratifying by ART status, patients not on ART were less likely to undergo open treatment, whereas those with ART underwent open treatment at similar rates to HIV-negative patients. Compared with the HIV-negative cohort, those with HIV, and on ART were significantly more likely to sustain malunion or nonunion following closed treatment. Patients with HIV are at increased risk for fracture, and they are more likely to experience adverse events following both closed and open management of distal radius fractures. Surgeons should pay close attention to bone healing in patients with HIV, and future research should investigate the causes of these adverse events and assess their modifiable risk factors. Prognostic II.

Revision Unicompartmental Knee Arthroplasty: Worse than a Primary, but Better than a Revision Total Knee Arthroplasty.

Revision of a unicompartmental to a total knee arthroplasty (TKA) is often compared to primary TKA with regard to its technical difficulty and complication rates. We sought to compare medical and surgical complications following revision unicompartmental knee arthroplasty (UKA) to those following primary TKA and aseptic revision TKA. A national administrative claims database was queried for patients undergoing revision UKA between 2010 and 2019. Patients undergoing revision of a UKA were matched to patients undergoing primary TKA and aseptic revision TKA based on age, sex, Elixhauser Comorbidity Index, payer status, and a history of obesity, osteoporosis, tobacco use, and alcohol use disorder. Revision-free survivorship as well as 2-year and 90-day complication rates were compared. Multivariable logistic regression analysis was performed to determine the independent risk of medical and surgical complications. A total of 3,924 matched primary TKAs, revision of a failed UKA, and aseptic revision TKA patients were included. Overall survivorship was 96.9% (95% confidence interval [CI] 95.9 to 97.8) for primary TKA, 93.4% (95% CI 92.1 to 94.8) for revision UKA, and 89.8% (95% CI 88.2 to 91.5) for aseptic revision TKA at 2-year follow-up (P < 0.001). At two years, revision UKA patients had higher rates of aseptic loosening (2.2 versus 0.8%, P= 0.004), instability (2.4 versus 0.8%, P= 0.002), and mechanical failures (3.0 versus 1.5%, P= 0.012) than primary TKA patients. The 90-day complication rates were comparable between primary TKA and revision UKA patients (all P > 0.05); the risk of reoperation, acute kidney injury, wound dehiscence, hematoma, and transfusion were all higher in the revision TKA than in the revision UKA cohort (all P < 0.05). Revision-free survivorship and arthroplasty-related complications at two years following revision UKA are lower than that for primary TKA, but higher than that for aseptic revision TKA, whereas medical complications are similar to those following primary TKA.

Incidence and risk factors for complications following cervical epidural steroid injections.

Cervical epidural steroid injections (CESIs) are commonly used in management of cervical pathology. While severe complications have been reported, they are rare, and thus their incidence and risk factors have not been well characterized. To determine the incidence of complications 7, 30, and 90 days after CESI and to identify associated risk factors. Retrospective cohort study of a large, national administrative claims database (MeritiveTM Marketscan®). The study included 229,412 patients (mean age 52.2 ± 11.3 years, 57.1% female) undergoing 448,209 CESIs from 2008-2015. Complication rates following CESI, and risk factors for complication. Adults undergoing a CESI with active enrollment for one year prior to and 90 days after CESI were included. Patients with neoplasm, fracture, infection, inflammatory spondyloarthropathy or prior cervical surgery within one year preceding CESI were excluded. Multivariable repeated measures logistic regression models were used to identify risk factors for complications at 7, 30, and 90 days. Complications were stratified into procedural and medical complications. Each time point was modeled separately with Bonferroni adjustment for the multiple time points. Complications increased from 1.7% to 4.1%, to 8.0% within 7, 30, and 90 days, respectively. Procedural complications occurred in 0.6% of cases within 7 days, with neurologic complications occurring in 0.5% of cases. Medical complications occurred in 1.1%, 3.6%, and 7.2% within 7, 30 and 90 days, respectively. After multivariable risk adjustment, a transforaminal approach was associated with greater odd for procedural complications within 7 days relative to an interlaminar approach (p<0.001), with an odds ratio (95% confidence interval) of 1.55 (1.35, 1.77). The transforaminal approach also was associated with greater odds of neurologic complications at 7 days [1.69 (1.45, 1.95); p<0.001]. A myelopathy diagnosis was not associated with risk of overall, procedural, medical, or neurological complications. The most influential factors independently associated with greater odds of any complication within 30 days included anticoagulant prescription [5.40 (4.55, 6.41); p<0.001] and history of venous thromboembolism [3.01 (2.40, 3.77); p<0.001]. The factors most strongly associated with procedural complications at 7 days included history of neurologic deficit [3.04 (2.65, 3.50); p<0.001] and antiplatelet medication prescription [2.21 (1.49, 3.27); p=0.003]. Complications following CESIs are infrequent. Neurologic complications were most common among procedural complications at 0.5% at 7 days. The transforaminal approach was associated with higher procedural complication rate compared to the interlaminar approach. Procedural and neurological complications were also associated with multiple factors including obesity, existing neurologic deficit, anxiety, and antiplatelet medication prescription. Attention should be given to these factors to mitigate procedural complications.

Lower obstetrician and gynecologist (OBGYN) supply in abortion-ban states, despite minimal state-level changes in the 2 years post-Dobbs.

Since the Dobbs v Jackson Women's Health Organization Supreme Court decision in June 2022, emerging reports suggest that the obstetrician and gynecologist (OBGYN) workforce is moving into states without abortion bans. Using a large national administrative database, we identified OBGYNs enrolling in new states from July 2017 through June 2024. We used difference-in-differences (DID) analyses to estimate the effect of Dobbs on enrollments by state abortion policy (ban vs no ban). Enrollments in ban states were lower than in no-ban states in most academic years (June-July) throughout the study period. In the 2 years post-Dobbs, DID models found no significant differences in enrollments in ban states relative to no-ban states. These findings indicate minimal state-level shifts in the OBGYN workforce following Dobbs. Past research has found that a complex constellation of factors drives physician movement, including state licensure, job availability, income, spousal job opportunities, and social support. While the effect of the Dobbs decision on the workforce are likely to be significant, the full impacts on the workforce will take years to fully unfold.

Trends in Overactive Bladder Therapy: Associations Between Clinical Care Pathways, Practice Guidelines, and Therapy Utilization Patterns.

Overactive bladder (OAB) is a chronic condition with significant financial and health-related consequences. Guidelines and treatment pathways were created to optimize care and provide a clinical framework for diagnosing and managing OAB. However, the impact of these efforts and patterns of medical treatment for OAB are poorly understood. Therefore, we sought to evaluate overall trends in therapy utilization before and after the 2014 American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) OAB guideline amendment and publication of the OAB clinical care pathway in 2016. In this retrospective cohort study, we analyzed data from Optum, a national administrative health and pharmacy claims database, between 2013 and 2018. All adult patients diagnosed with idiopathic OAB were identified by the International Classification of Diseases 9th and 10th Revision codes. Oral OAB therapies were identified using National Drug Codes, while third-line therapy procedures, onabotulinumtoxinA (BTX), sacral neuromodulation (SNM), and percutaneous tibial nerve stimulation (PTNS), were identified using Current Procedural Terminology (CPT) codes. The study's primary outcome was the annual number of OAB prescriptions filled by pharmacotherapy class and the number of minimally invasive therapies performed during the study period. The secondary outcome was the association between OAB therapy utilization and various clinical and sociodemographic factors. Patterns of care were analyzed from 2013 to 2018, and initial treatment with each therapy was collected, excluding repeat procedures from the analysis. 1 825 782 patients were included in the study. The mean age was 61.1 ± 16.7 years, and 1 071 420 patients were female (58.7%). The number of new OAB diagnoses increased by 369% from 2013 to 2017. During the 6-year study period, 347 052 (19%) patients were treated with oral and/or third-line therapies. The overall number of oral medications prescribed peaked in 2016, followed by a 17% decline between 2016 and 2018. In 2013, the two most prescribed oral medications were oxybutynin (46%) and solifenacin (31.8%). By 2018, mirabegron (18.5%) surpassed solifenacin (16.5%), with oxybutynin still accounting for most prescriptions written (55%). Eighty percent of all initial mirabegron prescriptions were filled by patients over the age of 65. The rate of third-line therapy procedures almost doubled between 2013 and 2018 (9-17 procedures per 1000 OAB patients, p < 0.001). Following the publication of the first OAB guidelines, there was an increase in OAB diagnoses, followed by a decrease in anticholinergic medication use, and a rise in beta-3 agonist utilization in patients over 65 years old. Additionally, there was greater adoption of third-line OAB therapies. These trends indicate that OAB therapy guidelines and clinical practice pathways may influence treatment patterns. Given the recent publication of the OAB guidelines, further studies are necessary to assess their impact on therapy utilization patterns.

Abstract 4118332: Suvorexant is associated with the reduced risk of feart failure rehospitalization in elderly patients with heart failure and insomnia

Background: Research that compares the safety of orexin receptor antagonists and other types of hypnotics prescribed to elderly patients with heart failure (HF) and insomnia remains lacking. This study aimed to compare an orexin receptor antagonist, Suvorexant, with benzodiazepines or Z-drugs for insomnia treatment and investigate the risk of HF-related rehospitalization in elderly patients with HF and insomnia. Methods: A national administrative claims database from April 2008 to December 2020 was utilized and analyzed. The study population, consisting of 1,159,937 patients aged ≥65 years, was randomly sampled from the database. Patients were then selected based on specific inclusion and exclusion criteria. Exposures were identified based on the classification of the first prescribed hypnotic. The follow-up period was continued considering the prescription interval and grace period. The end of follow-up was censored based on multiple criteria, including outcome occurrences (i.e., HF rehospitalization) and hypnotic classification changes. Kaplan–Meier survival analysis and Cox proportional hazards models were used. Hazard ratios were adjusted by propensity scores derived from patients’ background factors. Results: The analysis included 1,858 elderly who had their first HF-related hospitalization. They were categorized into Suvorexant, benzodiazepines and Z-drugs groups (N=490, 606 and 762, respectively). The average age for all participants was 82.7 ± 7.6 years, which is similar across three groups. Kaplan-Meier curves indicated a higher trend of HF-rehospitalization risk for benzodiazepines and Z-drugs groups than for Suvorexant. The adjusted hazard ratios were 2.77 (95% confidence intervals [CI]: 1.17-6.52) for benzodiazepines and 2.98 (95% CI: 1.33-6.68) for Z-drugs. Conclusion: Compared with benzodiazepines and Z-drugs, the use of suvorexant for insomnia treatment in elderly patients with HF indicates a potential for the reduced risk of rehospitalization due to HF exacerbation. The results of this study provide valuable information for the selection of hypnotics in elderly HF patients with concurrent insomnia.

Utilization of Surgical Fixation for Distal Radius Fractures in the United States: A Population-Based Cohort Study

In contrast to younger adult populations, clinical practice guidelines state that there is no difference in long-term functional outcomes in surgically versus nonoperatively treated distal radius fractures in patients ≥65 years old. In this study, we asked the following questions: (1) has treatment for distal radius fractures in younger and older adult populations changed over time? (2) What patient and surgeon factors are associated with treatment trends? Using a national administrative claims database, we identified patients aged ≥18 years with isolated, closed distal radius fractures, subdivided by age (18-64 years, ≥65 years old). We characterized the proportion of patients who underwent open reduction and internal fixation (ORIF) over time. We stratified our analysis by surgeon subspecialty, region, and mean area income. Changes in ORIF utilization over time were evaluated using linear regression models. The proportion of distal radius ORIF, including in patients aged ≥65 years, increased from 10.4% in 2012 to 15.1% in 2020. Of the ORIF procedures performed, hand surgeons accounted for an increasing proportion over time, with a corresponding decrease in those performed by general orthopedic surgeons. The proportion of ORIF increased over time in all US regions, with the largest rate of increase in the Midwest for patients aged ≥65 years and Northeast for patients aged 18-64 years. Patients living in areas with mean family income ≥$65,000 were more likely to undergo ORIF. The proportion of distal radius ORIF including in older adult populations is increasing in all US regions, and an increasing proportion is performed by hand surgeons. Further analysis of the drivers of these trends is warranted, given the rising incidence of surgical treatment in older patients, which could reflect evolving patient activity demands and suggest a need to further evaluate conventional treatment algorithms based on age.

Increasing Utilization of Extended Oral Antibiotic Prophylaxis Following Total Knee Arthroplasty from 2010 to 2022

Extended oral antibiotic (EOA) prophylaxis has been shown to reduce rates of periprosthetic joint infection in high-risk patients following total knee arthroplasty (TKA). Although national societies' recommendations against their use and clinical efficacy remain controversial, the increase in the literature surrounding EOA prophylaxis suggests a potential change in practice patterns that may warrant the creation of national guidelines. The purpose of this study was to investigate the trends in the utilization of EOA prophylaxis following TKA from 2010 to2022. Patients who underwent primary or aseptic revision TKA between 2010 and 2022 were identified in a national administrative claims database. Temporal trends in EOA usage following primary or revision TKA were calculated, and secondary analysis examined rates of utilization across demographics, including patients considered at high risk for infection. In total, 1,258,759 primary and 91,530 aseptic revision TKA patients were included in this study. From 2010 to 2022, EOA prescriptions increased by 321 and 368% following primary and revision TKA, respectively. Rates of utilization among high-risk individuals were similar to those of the general population. The use of EOA prophylaxis after TKA has increased significantly since 2010. Given their increasing usage and variation in prescription patterns among patients at high risk of infection, guidelines surrounding their use are necessary to promote antibiotic stewardship while preventing rates of infection.

The incidence, providers involved, and patient factors associated with diagnosis of specific lumbar spine pathology subsequent an initial nonspecific low back pain diagnosis

BACKGROUND CONTEXTLow back pain (LBP) is an exceedingly common diagnosis with significant societal and healthcare burden. While nonspecific LBP diagnoses are frequently assigned and often resolve soon thereafter, some patients may subsequently be diagnosed with specific underlying lumbar spine pathology. PURPOSETo characterize the incidence, providers involved, and factors associated with specific pathology LBP (SP-LBP) diagnosed subsequent an initial nonspecific LBP (NS-LBP) diagnosis. STUDY DESIGNRetrospective cohort study. PATIENT SAMPLEAdult patients diagnosed with NS-LBP between 2010 and Q1 2022 were abstracted from a large national administrative database. OUTCOME MEASUREMENTSIncidence of subsequent SP-LBP diagnoses, providers involved, and factors associated with SP-LBP diagnoses in the 12-months following initial NS-LBP diagnosis. METHODSAdult patients diagnosed with NS-LBP were identified based on International Classification of Disease (ICD) codes ICD-9-D-724.2 and ICD-10-D-M54.5. These patients diagnosed with new NS-LBP were reported based on incidence per 100,000 covered lives. Exclusion criteria included: patients less than 18 years old, those with any prior NS-LBP diagnosis, any prior SP-LBP diagnoses, and those with trauma, neoplasm, or infection diagnosed within 3-months prior to the initial NS-LBP diagnosis. Patients who subsequently received SP-LBP diagnoses within 12-months following initial NS-LBP were then identified. Patients were characterized based on age, sex, history of cancer, obesity, opioid use disorder, anxiety, and depression and then compared with patients receiving no additional LBP diagnosis by univariable and multivariable analysis. Provider specialties who initially diagnosed NS-LBP and those involved with subsequent SP-LBP diagnoses were identified. RESULTSNS-LBP was identified for a robust cohort of 6,861,235 patients, yielding an incidence of 4,258 diagnoses per 100,000 covered lives. Subsequent SP-LBP diagnoses were identified for 562,982 (8.21%) within 12-months, of which 62.57% of these SP-LBP diagnoses occurred within 3-months. The most common of these subsequent diagnoses included radiculopathy (3.01% of the overall study population), disc degeneration (2.84%), and disc herniation (1.23%). Patients receiving a subsequent SP-LBP diagnosis were more likely older (per year increase, odds ratio [OR] 1.02), male (OR 1.10), had a history of cancer (OR 1.32), obesity (OR 1.30), opioid use disorder (OR 1.17), anxiety (OR 1.21), or depression (OR 1.17) (p<.001 for all). NS-LBP was initially diagnosed predominantly by primary care providers (PCPs) in family medicine (44.09%) and internal medicine (27.49%). These PCP providers also contributed to the majority of SP-LBP diagnoses, while specialty providers contributed to a greater degree in SP-LBP diagnoses than NS-LBP. CONCLUSIONNS-LBP is a common diagnosis that usually, 91.79% of the time, does not subsequently convert to a SP-LBP diagnosis within 12-months. This may reflect improvement of LBP symptoms and/or accurate initial triage, largely by PCPs. Of the minority of patients receiving a subsequent SP-LBP diagnosis, various patient factors were significantly associated, and a greater degree of specialty providers were involved, which highlights potential contributors to diagnostic difficulty of SP-LBP and the multidisciplinary nature of LBP management.

Trends in Pregnancy Outcomes in People with Sickle Cell Disease and Medicaid Insurance (2006-2018).

Background: Although the risk of pregnancy-related morbidity and mortality in people with sickle cell disease (SCD) is well established, limitations in data sources and heterogeneity in outcome reporting hinder the ability to make meaningful comparisons between historical and contemporary populations. This study used a national administrative claims database to compare pregnancy outcomes in people with SCD between 2006-2011 and 2012-2018. Materials and Methods: Pregnant females aged 16-44 years with SCD were identified from the Centers for Medicare and Medicaid Service Analytic eXtract, along with a control cohort of pregnant people. People were followed from first identified pregnancy until one year postpartum. Outcomes of interest were identified with ICD-9 or 10 codes. Results: We included 6,388 people with SCD and 17,278 controls in analyses. Preeclampsia/eclampsia, hypertension, thrombosis, poor fetal growth, preterm delivery, and postpartum hemorrhage were all more common in people with SCD compared with controls. Maternal death occurred in 0.5% of people with SCD versus <0.1% in those without SCD (p < 0.001). When comparing infant deliveries in 2006-2011 to those occurring in 2012-2018, all pregnancy-related complications except preterm delivery, including maternal death, occurred at similar or higher frequencies in more recent years. Conclusions: Between 2006 and 2018, maternal death occurred in approximately 1 out of every 200 publicly insured people with SCD in the year following infant delivery. Our work confirms, on a national-level, that pregnancy-related outcomes in people with SCD in the United States have not improved with time, and that some complications have in fact increased in frequency.

Association of novel antihyperglycemic drugsversusmetformin with COPD exacerbations

BackgroundDipeptidyl peptidase-4 inhibitors (DPP-4 Is), glucagon-like peptidase 1 receptor agonists (GLP-1 RAs), and sodium glucose co-transporter-2 inhibitors (SGLT-2 Is) may contribute to better control of chronic obstructive pulmonary disease (COPD) due to their anti-inflammatory effects, like those observed with metformin. We aimed to investigate the association of these novel antihyperglycemic drugsversusmetformin with fewer COPD exacerbations in patients with type 2 diabetes (T2DM) comorbid with COPD.MethodsUsing the national administrative database covering 99% of the medical facilities in Japan, we constructed three active comparators new-user cohorts comprising 36 317 patients with T2DM and COPD who initiated treatment with the novel antihyperglycemic drugs and metformin between 2014 and 2022. Patients’ backgrounds were balanced using overlap propensity score weighting. We calculated the hazard ratios (HRs) and their 95% confidence intervals (CIs) for the initial occurrence of COPD exacerbation requiring systemic corticosteroids using a weighted Cox proportional hazards model.ResultsDPP-4 Is were associated with a higher incidence of exacerbations requiring systemic corticosteroids (22.4versus20.4 per 100 person-years; HR [95% CI] 1.16 [1.07–1.25]) compared with metformin. In contrast, the incidence of such exacerbations in the GLP-1 RAs (30.1versus24.4 per 100 person-years; HR [95% CI] 1.07 [0.87–1.32]) and SGLT-2 Is (20.7versus21.8 per 100 person-years; 1.00 [0.94–1.06]) groups were comparable with that in the metformin group.ConclusionsWhile DPP-4 Is were associated with poorer control of COPD compared with metformin, GLP-1 RAs and SGLT-2 Is offered COPD control comparable to that of metformin.

Maximising the Quality of Stroke Care: Reporting of Data Collection Methods and Resourcing in National Stroke Registries: A Systematic Review.

Stroke registries are tools for improving care and advancing research. We aim to describe the methodology and resourcing of existing national stroke registries. We conducted a systematic search of the published, peer-reviewed literature and grey literature examining descriptions of data collection methods and resourcing of national stroke registries published from 2012 to 2023. The systematic review was registered in PROSPERO (CRD42023393841). 101 records relating to 21 registries in 19 countries were identified. They universally employed web-based platforms for data collection. The principal profession of data collectors was nursing. All included the acute phase of care, 28% (6) registered the pre-hospital (ambulance) phase and 14% (3) included rehabilitation. 80% (17) collected outcome data. The registries varied in their approach to outcome data collection; in 9 registries it was collected by hospitals, in 2 it was collected by the registry, and 7 had linkage to national administrative databases allowing follow-up of a limited number of end points. Coverage of the total number of strokes varies from 6 to 95%. Despite widespread use of Electronic Health Records (EHRs) the ability to automatically populate variables remained limited. Governance and management structures are diverse, making it challenging to compare their resourcing. Data collection for clinical registries requires time and necessary skills and imposes a significant administrative burden on the professionals entering data. We highlight the role of clinical registries as powerful instruments for quality improvement. Future work should involve creating a central repository of stroke registries to enable the development of new registries and facilitate international collaboration.

Favorable impact of azithromycin on patients in the intensive care unit with coronavirus disease 2019: Insights from the first wave using a Japanese database

BackgroundAzithromycin has favorable effects on critical respiratory diseases owing to its antimicrobial and anti-inflammatory properties. During the early stages of the coronavirus disease 2019 (COVID-19) pandemic, azithromycin was frequently administered before specific treatments were developed. However, the efficacy of this treatment has not been verified. We retrospectively investigated the effects of its intravenous (IV) administration in patients with severe/critical COVID-19 using the National Administrative Database of Japan during the first wave (February–April 2020). MethodsPatients were categorized based on whether they received IV azithromycin within three days of hospitalization. An overlap weighting method with estimated propensity scores was used to reduce bias. ResultsAmong the 830 patients with severe/critical COVID-19, 148 (17.8 %) received azithromycin, and 682 (82.2 %) did not. After adjustment, the use of azithromycin was associated with a shorter duration of intensive care unit (ICU) management (−3.48 days, 95 % confidence interval [CI]: 4.59 to −2.38). However, other endpoints, including mortality rate, duration of mechanical ventilation, and duration of hospital stay, did not suggest any associations. Furthermore, of the 115 ICU patients, 27 (23.5 %) were treated with IV azithromycin and 88 (76.5 %) were not. After adjustment, azithromycin was associated with favorable outcomes, including reduced in-hospital mortality (odds ratio [OR], 0.45, 95 % CI: 0.22 to 0.92), 30-day mortality (OR, 0.46, 95 % CI: 0.22 to 0.94), and a shorter duration of ICU management (−2.94 days, 95 % CI: 5.15 to −0.73). ConclusionWe verified that IV azithromycin was associated with favorable impact in patients with COVID-19 requiring ICU management.