Ninth Revision Procedure Codes Research Articles

Ten-Year Follow-Up of Mitral Valve Replacement With the Epic Porcine Valve in a Medicare Population

BackgroundBioprosthetic surgical mitral valve replacement (SMVR) remains an important treatment option in the era of transcatheter valve interventions. This study presents 10-year clinical outcomes of Medicare beneficiaries who underwent SMVR with a contemporary low-profile mitral porcine valve. MethodsThis was a single-arm observational study using Medicare fee-for-service claims data. Deidentified patients undergoing SMVR with the Epic mitral valve (Abbott) in the United States between January 1, 2008 and December 31, 2019 were selected by International Classification of Diseases, Ninth and Tenth Revision procedure codes and then linked to a manufacturer device tracking database. All-cause mortality, heart failure (HF) rehospitalization, and mitral valve reintervention (surgical or transcatheter valve-in-valve) were evaluated at 10 years by using the Kaplan-Meier method. ResultsAmong 75,739 Medicare beneficiaries undergoing SMVR during the study period, 14,015 received the Epic mitral valve (Abbott), 76.5% (10,720) of whom had underlying HF. The mean age was 74 ± 8 years. Survival at 10 years in patients without preoperative HF was 40.4% (95% CI, 37.4%-43.4%) compared with 25.4% (95% CI ,23.8%-27.0%) for patients with HF (P < .001). The 10-year freedom from HF rehospitalization was 51.3% (95% CI, 49.4%-53.1%). Freedom from mitral valve reintervention was 91.4% (95% CI, 89.7%-92.7%) at 10 years. ConclusionsThis real-world nationwide study of Medicare beneficiaries receiving the Epic mitral valve demonstrates >90% freedom from all-cause valve reintervention and >50% freedom from HF rehospitalization at 10 years after implantation. Long-term survival and HF rehospitalization in this population with mitral valve disease treated with SMVR was found to be affected by underlying HF.

Risk Factors for Readmission Following Surgical Decompression for Spinal Epidural Abscesses: An Analysis of 4595 Patients.

Retrospective cohort study. The study aimed to (1) compare baseline demographics of patients undergoing surgery for SEA who were/were not readmitted; (2) identify risk factors for 90-day readmissions; and (3) quantify 90-day episode-of-care health care costs. Spinal epidural abscess (SEA), while rare, occurring ~2.5-5.1/10,000 admissions, may lead to permanent neurologic deficits and mortality. Definitive treatment often involves surgical intervention via decompression. A search of the PearlDiver database from 2010 to 2021 for patients undergoing decompression for SEA identified 4595 patients. Cohorts were identified through the International Classification of Disease, Ninth Revision (ICD-9), ICD-10, and Current Procedural Terminology codes. Baseline demographics of patients who were/were not readmitted within 90 days following decompression were aggregated/compared, identifying factors associated with readmission. Using Bonferroni correction, a P -value<0.001 was considered statistically significant. Readmission within 90 days of surgical decompression occurred in 36.1% (1659/4595) of patients. While age/gender were not associated with readmission rate, alcohol use disorder, arrhythmia, chronic kidney disease, ischemic heart disease, and obesity were associated with readmission. Readmission risk factors included fluid/electrolyte abnormalities, obesity, paralysis, tobacco use, and pathologic weight loss ( P <0.0001). Mean same-day total costs ($17,920 vs. $8204, P <0.001) and mean 90-day costs ($46,050 vs. $15,200, P <0.001) were significantly higher in the readmission group. A substantial proportion of patients (36.1%) are readmitted within 90 days following surgical decompression for SEA. The top 5 risk factors in descending order are fluid/electrolyte abnormalities, pathologic weight loss, tobacco use, pre-existing paralysis, and obesity. This study highlights areas for perioperative medical optimization that may reduce health care utilization.

Outcomes of Acute Myocardial Infarction in Female Patients With Type 1 Diabetes Mellitus

There is a paucity of data on acute myocardial infarction (AMI) outcomes for female patients with type 1 diabetes (T1DM) compared with men. The National Inpatient Sample Database was queried from 2011 to 2019 for relevant International Classification of Diseases, Ninth and Tenth Revision procedural and diagnostic codes. Hospitalizations with an admitting diagnosis of non-ST-elevation myocardial infarction or ST-elevation myocardial infarction were compared between male and female patients with T1DM. A multivariate logistic regression adjusting for baseline characteristics and primary diagnosis was performed. A p <0.001 was considered significant. A total of 50,020 hospitalizations for AMI in patients with T1DM were identified, of which 23,980 (47.9%) were women. The baseline characteristics are listed in Table 1. Women experienced similar rates of all-cause and inhospital mortality (5.0% vs 4.7%, p=0.082). However, after adjusting for baseline characteristics and primary diagnosis, women had higher odds of mortality (adjusted odds ratio [aOR] 1.26, 95% confidence interval [CI] 1.15 to 1.38). Women were less likely to undergo cardiac catheterization (65.7% vs 68.2%; aOR 0.90, 95% CI 0.86 to 0.94) and coronary artery bypass grafting (5.6% vs 6.9%; aOR 0.76, 95% CI 0.70 to 0.82, p <0.001 for both). There was no difference in the use of percutaneous coronary intervention (41.0% vs 41.9%; aOR 1.01, 95% CI 0.97 to 1.05, p=0.042). The female gender is not protective against AMI in patients with T1DM. Women with T1DM, on average, experience AMI at the same age as men, are less likely to undergo surgical revascularization, and have higher odds of mortality.

Survival, Reintervention, and Value of Open and Endovascular Repair for Chronic Mesenteric Ischemia

There are limited analyses of survival and postoperative outcomes in chronic mesenteric ischemia (CMI) using data from large cohorts. Current guidelines recommend open repair (OR) for younger, healthier patients when long-term benefits outweigh increased perioperative risks or for poor endovascular repair (ER) candidates. This study investigates whether long-term survival, reintervention, and value differ between these treatment modalities. A retrospective cohort analysis was performed on data extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payer database containing demographics, diagnoses, treatments, and charges. Patients were selected for CMI and subsequent ER or OR using International Classification of Diseases, Ninth Revision codes. Patients with peripheral arterial disease were excluded to account for ambiguity in the International Classification of Diseases, Ninth Revision procedure code for angioplasty of noncoronary vessels, which includes angioplasty of upper and lower extremity vessels. Kaplan-Meier analysis was used to compare 1-year and 5-year survival and reintervention between treatment modalities using a propensity-matched cohort. Cox proportional hazards testing was performed to find factors associated with 1-year and 5-year survival and reintervention. Analysis of procedural value was performed using linear regression. From 2000 to 2014, 744 patients met inclusion criteria. Of these, 209 (28.1%) underwent OR and 535 (71.9%) ER. No difference between propensity-matched groups was found in 1-year (P=0.46) or 5-year (P=0.91) survival. Congestive heart failure (hazard ratio [HR]: 2.8, 95% confidence interval [CI]: 1.7-4.4; P<0.01), cancer (HR: 2.8, 95% CI: 1.3-5.8; P<0.01), and dysrhythmia (HR: 1.8, 95% CI: 1.1-2.8; P=0.02) correlated with 1-year mortality. Cancer (HR: 2.9, 95% CI: 1.6-5.5; P<0.01), congestive heart failure (HR: 2.2, 95% CI: 1.5-3.2; P<0.01), chronic pulmonary disease (HR: 1.4, 95% CI: 1.0-2.0; P=0.04), and age (HR: 1.03, 95% CI: 1.01-1.05; P<0.01) correlated with 5-year mortality. Treatment modality was not associated with reintervention at 1year on Kaplan-Meier analysis (P=0.29). However, ER showed increased instances of reintervention at 5years (P<0.01). Additionally, ER was associated with an increased 5-year value (0.7±0.9 vs. 0.5±0.5 life years/charges at index admission [$10k], P<0.01; b coefficient: 0.2, 95% CI: 0.1-0.4, P<0.01). This is the largest retrospective propensity-matched single-study cohort to analyze long-term survival outcomes after intervention for CMI. Long-term mortality was independent of treatment modality and rather was associated with patient comorbidities. Therefore, treatment selection should depend on anatomic considerations and long-term value. ER should be considered over OR in patients with amenable anatomy based on the superior procedural value.

Initiation and Treatment Discontinuation of Medications for Opioid Use Disorder in Pregnant People Compared With Nonpregnant People.

To examine the association between pregnancy and medications for opioid use disorder (MOUD) initiation and discontinuation among reproductive-aged people receiving treatment for opioid use disorder (OUD) in the United States. We conducted a retrospective cohort study of people with gender recorded as female, aged 18-45 years, in the Merative TM MarketScan ® Commercial and Multi-State Medicaid Databases (2006-2016). Opioid use disorder and pregnancy status were identified based on inpatient or outpatient claims for established International Classification of Diseases, Ninth and Tenth Revision diagnosis and procedure codes. The main outcomes were buprenorphine and methadone initiation and discontinuation, determined by using pharmacy and outpatient procedure claims. Analyses were conducted at the treatment episode level. Adjusting for insurance status, age, and co-occurring psychiatric and substance use disorders, we used logistic regression to estimate MOUD initiation and used Cox regression to estimate MOUD discontinuation. Our sample included 101,772 reproductive-aged people with OUD, encompassing 155,771 treatment episodes (mean age 30.8 years, 64.4% Medicaid insurance, 84.1% White), of whom 2,687 (3.2%, encompassing 3,325 episodes) were pregnant. In the pregnant group, 51.2% of treatment episodes (1,703/3,325) involved psychosocial treatment without MOUD, in comparison with 61.1% (93,156/152,446) in the nonpregnant comparator group. In adjusted analyses assessing likelihood of initiation for individual MOUD, pregnancy status was associated with an increase in buprenorphine (adjusted odds ratio [aOR] 1.57, 95% CI 1.44-1.70) and methadone initiation (aOR 2.04, 95% CI 1.82-2.27). Discontinuation rates of MOUD at 270 days were high for both buprenorphine (72.4% for nonpregnant episodes vs 59.9% for pregnant episodes) and methadone (65.7% for nonpregnant episodes vs 54.1% for pregnant episodes). Pregnancy was associated with a decreased likelihood of discontinuation at 270 days for both buprenorphine (adjusted hazard ratio [aHR] 0.71, 95% CI 0.67-0.76) and methadone (aHR 0.68, 95% CI 0.61-0.75), in comparison with nonpregnant status. Although a minority of reproductive-aged people with OUD in the United States are initiated on MOUD, pregnancy is associated with a significant increase in treatment initiation and a reduced risk of medication discontinuation.

Severe Maternal Morbidity in Twins.

While twin gestations are at increased risk of severe maternal morbidity (SMM), there is limited information about timing and causes of SMM in twins. Furthermore, existing data rely on screening definitions of SMM because a gold standard approach requires chart review. We sought to determine the timing and cause of SMM in twins using a gold standard definition outlined by the American College of Obstetricians and Gynecologists (ACOG). We used a perinatal database to identify all twin deliveries from 1998 to 2013 at a single academic medical center (n = 2,367). Deliveries were classified as screen positive for SMM if they met any of the following criteria: (1) one of the Centers for Disease Control and Prevention (CDC) International Classification of Diseases Ninth Revision diagnosis and procedure codes for SMM; (2) a prolonged postpartum length of stay (>3 standard deviations beyond mean length of stay by mode of delivery); or (3) maternal intensive care unit admission. We identified true cases of SMM through medical record review of all screen-positive deliveries using the definition of SMM outlined in the ACOG Obstetric Care Consensus. We also determined cause and timing of SMM. A total of 165 (7%) of twin deliveries screened positive for SMM. After chart review of all screen-positive cases, 2.4% (n = 56) were classified as a true case of SMM using the ACOG definition for a positive predictive value of 34%. The majority of SMM occurred postpartum (65%). Hemorrhage was the most common cause of SMM, followed by hypertensive and pulmonary etiologies. Commonly used approaches to screen for SMM perform poorly in twins. This has important implications for quality initiatives and epidemiologic studies that rely on screening definitions of maternal morbidity. Our study demonstrates that the immediate postpartum period is a critical time for maternal health among women with twin pregnancies. · Screening approaches for SMM have low positive predictive value in twins.. · Hemorrhage, hypertensive, and pulmonary complications were the most common morbidities.. · SMM was most common postpartum..

Sociodemographic Disparities in Access to Cleft Rhinoplasty.

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Rates of Complications and Reoperation after Myomectomy—the Impact of Surgical Approach: A Statewide Population-based Cohort Study from 2005–2018

To assess rates of and factors associated with complications and reoperation after myomectomy. Population-based cohort study. All non-Veterans Affairs facilities in the state of California from January 1, 2005, to December 31, 2018. Women undergoing abdominal or laparoscopic myomectomy for myoma disease were identified from the Office of Statewide Health Planning and Development datasets using appropriate International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes. Demographics, surgery facility type, facility surgical volume, and surgical approach were identified. Primary outcomes included complications occurring within 60 days of surgery and reoperations for myomas. Patients were followed up for over an average of 7.3 years. Univariate and multivariable associations were explored between the above factors and rates of complications and reoperation. All odds ratios (ORs) are adjusted ORs. Of the 66 012 patients undergoing myomectomy, 5265 had at least one complication (8.0%). Advanced age, black, Asian race, MediCal and Medicare payor status, academic facility, and medical comorbidities were associated with increased odds of a complication. Minimally invasive myomectomy (MIM) was associated with decreased complications compared with abdominal myomectomy (AM) (OR, 0.29; 95% confidence interval [CI], 0.25-0.33; p <.001). Overall, 17 377 patients (26.3%) underwent reoperation. Medicare and MediCal payor status and medical comorbidities were associated with increased odds of a repeat surgery. Reoperation rates were higher in the MIM group over the entire study period (OR, 2.33; 95% CI, 1.95-2.79; p <.001). However, the odds of reoperation after MIM decreased each year (OR, 0.93; 95% CI 0.92-0.95; p <.001), with the odds of reoperation after AM surpassing MIM in 2015. This study identifies outcome disparities in the surgical management of myomas and describes important differences in the rates of complications and reoperations, which can be used to counsel patients on surgical approach. These findings suggest that MIM can be considered a lasting and safe approach in properly selected patients.

Treatment Trends and Inpatient Mortality in Isolated Severe Traumatic Brain Injury Using the National Trauma Data Bank

Severe traumatic brain injury (TBI) remains a leading cause of morbidity and mortality. Despite recommendations from the Brain Trauma Foundation, there is wide variability in treatment paradigms for severe TBI. We aimed to elucidate the variability of treatment, particularly neurosurgical procedures and how it affects mortality. Adult patients (<65 years old) with a severe isolated TBI who were treated at an American College of Surgeons level I trauma center were identified in the National Trauma Data Bank for the years 2007-2016. International Classification of Diseases, Ninth Revision procedure codes were used to identify primary treatment approaches: intracranial pressure (ICP) monitoring and cranial surgery (craniotomy/craniectomy). Among 25,327 patients with severe isolated TBI, 14.0% underwent ICP and 18.0% underwent cranial surgery. ICP monitoring reduced the odds of mortality (odds ratio 0.89, 95% confidence interval [0.81, 0.98]), but not the extent of cranial surgery (odds ratio 0.71, 95% confidence interval [0.65, 0.77]). Brain Trauma Foundation guidelines recommend placement of an ICP monitor for severe TBI; however, only 14% of patients with isolated, severe TBI underwent ICP monitoring in 2007-2016. ICP monitoring and cranial surgery decrease the odds of inpatient mortality in patients with severe TBI.

Effect of Sickle Cell Trait on Total Hip Arthroplasty in a Matched Cohort.

It is unclear if sickle cell trait (SCT) carrier status conveys an increased risk for poor outcomes following total hip arthroplasty (THA). The purpose of this study is to compare short-term clinical outcomes of THA for patients with SCT vs matched controls. Patient records were queried from the PearlDiver database using International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes. Patients with SCT who underwent THA were matched 1:1 with controls across age, gender, Elixhauser Comorbidity Index, obesity, and US region. Thirty-day and 90-day rates of systemic complications and 1-year and 2-year rates of joint complications were compared with logistic regression. In total, 1646 patients were assigned to each cohort. In the 30-day and 90-day postoperative periods, SCT carriers had a higher likelihood of cerebrovascular accident, anemia, acute renal failure, pneumonia, sepsis, deep vein thrombosis, pulmonary embolism, and respiratory failure (all P < .05). SCT carriers exhibited significantly higher risk of periprosthetic joint infection at both 1 (3.5% vs 2.1%; odds ratio [OR] 1.91, 95% confidence interval [CI] 1.22-2.99) and 2 years (3.7% vs 2.6%; OR 1.63, 95% CI 1.07-2.49) postoperatively. Prosthetic loosening was also significantly more likely for SCT carriers within 1 year (1.3% vs 0.3%; OR 4.49, 95% CI 1.75-13.86). Patients with SCT exhibited significantly higher risk for systemic complications, periprosthetic joint infection, and prosthetic loosening after THA. Increased perioperative efforts should be made to prevent hypoxia, acidosis, and dehydration, as these states increase red blood cell sickling, which may reduce complication rates and improve outcomes in patients with SCT.

594 Dermal Matrix versus Autologous Grafting for Full-Thickness Burns of Head and Neck: Trends, Outcomes, Cost

IntroductionBurns of the head and neck are particularly devastating, commonly occurring due to accidental flame or scald injury. Autologous grafting has traditionally been used for reconstruction in this area. Recently the use of dermal matrices as a reconstructive alternative has increased. This study compares annual trends, outcomes, and hospital costs between head and neck burn patients who underwent reconstruction with dermal matrix or autologous grafting.MethodsThe U.S Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was queried from 2012 to 2016. Patients with head and neck burns treated with dermal matrix or autologous graft were identified using International Classification of Disease Ninth and Tenth Revision diagnosis and procedure codes. Demographic, clinical characteristics, and outcome measures were reported. χ 2 and Student’s t-tests were used for univariate survey-adjusted comparisons between groups. Multivariate survey-adjusted linear regressions were used to identify associations between surgical intervention, length of stay and cost of hospitalization. Analyses were conducted with RStudio (1.4.1717).ResultsA total of 6,730 patients met inclusion criteria; 2,855 underwent reconstruction dermal matrix and 3,875 with autologous graft. There was an increasing number of patients undergoing dermal matrix reconstruction each year, peak in 2016 (1,450, 50.8%). The dermal matrix group was younger (33.7 vs 39.9, p< 0.001) had fewer females (27.3% vs 38.2%, p=0.003) and fewer inhalation injury (4.0% vs 11.0%, p< 0.001). The dermal matrix group had a shorter length of stay (11.2 vs 27.8, p< 0.001) and more home discharges (80.4% vs 53.4%, p< 0.001); they had lower Elixhauser Comorbidity Index score for readmission (6.57 vs 11.92, p< 0.001) and in hospital mortality (4.76 vs 9.69, p< 0.001). Median cost of care was lower for the dermal matrix group ($17,858 vs $59,860, p< 0.001). Multivariable regression demonstrated that reconstruction with dermal matrix was independently associated with decreased length of stay (11.01 [7.95 - 14.07], p< 0.001) and decreased cost ($38,297 [23,813], p< 0.001).ConclusionsOperative management of head and neck burns with dermal matrix is associated with a shorter hospital stay, greater likelihood of home discharge, and decreased hospital costs. Patients with autologous grafting had higher rates of inhalation injury, which may account for longer hospital stays and increased discharges to nursing facilities. A limit of this study is the inability to differentiate patients undergoing staged procedures. Further study is needed to evaluate factors contributing to faster discharges home in the head and neck burn population.

Modular Metal-Backed Tibial Components Provide Minimal Mid-Term Survivorship Benefits Despite Increased Cost and Frequency of Use: A Retrospective Review of the American Joint Replacement Registry Database

BackgroundPrevious studies have demonstrated equivalent survivorship of modular metal-backed tibial (MBT) and all-polyethylene tibial (APT) components. The purpose of this study is to compare the utilization and outcomes of APT and MBT components in a large US database. MethodsThe American Joint Replacement Registry was queried to identify all patients undergoing primary total knee arthroplasty (TKA) during the study period from 2012 to 2019. These patients were divided into cohorts based on tibial component (APT or MBT). Cohort demographics including gender, hospital size, hospital teaching status, region, age, and Charlson Comorbidity Index were reported with descriptive statistics. Overall reoperation rates and revisions for infection, aseptic loosening, periprosthetic fracture, manipulation under anesthesia, and revision for other reasons were identified using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes and compared across APT and MBT cohorts. Kaplan-Meir survival analysis was performed based on reason for reoperation for APT and MBT. ResultsDuring the study period, 703,007 TKAs were reported with 97.8% utilizing MBT and 2.2% utilizing APT components. Despite the introduction of alternative payment models during the study period, the utilization of APT decreased from 5.8% in 2012 to 1.7% in 2019. The survival of APT and MBT TKAs were similar across the study period: 98.1% vs 98.6% at 8 years. The rate of reoperation for all-causes was higher for APT compared to MBT (1.36% vs 1.00%; odds ratio 1.52). ConclusionDespite their paucity of use and lower cost APT remained within a 0.4% margin of survivorship when compared to MBT implants for up to 8 years. Level of EvidenceLevel III, retrospective.

Safety of Influenza Vaccination During Orthopaedic Surgery Hospitalizations.

Despite national recommendations, influenza vaccination rates during hospitalizations remain low. Inpatient hospitalization for orthopaedic surgery remains a largely missed opportunity for vaccination. To address potential concerns regarding safety, we evaluated whether influenza vaccination during hospitalization for orthopaedic surgery increases evaluations for infection postdischarge because patients and clinicians often cite fear of this potential outcome. This was a retrospective cohort study that was conducted among patients of a large integrated healthcare organization aged ≥6 months who were hospitalized for an orthopaedic surgery (defined by International Classification of Diseases, Ninth Revision procedure codes) between September 1 and March 31 from 2011 to 2014. Using propensity score matching (1:1) to adjust for confounding, we assessed the association between influenza vaccination during an inpatient stay for orthopaedic surgery and rates of readmission, emergency department visits, outpatient visits, fever (temperature ≥38.0°C), and evaluations for infections less than 7 days postdischarge. Overall, 2,395 hospitalizations with inpatient vaccination and 21,708 hospitalizations without inpatient vaccination were identified. Following successful balance of covariates (standardized difference <0.1 for all covariates) through 1:1 propensity score matching, we included 2,376 exposed patients and 2,376 unexposed patients in the matched analysis. In adjusted analyses, compared with those who were not vaccinated during hospitalization, those vaccinated during an inpatient stay for orthopaedic surgery had no statistically significant increase in readmission (relative risk [RR] = 1.00, 95% confidence interval [CI]: 0.75 to 1.34), emergency department visits (RR = 1.14, 95% CI: 0.93 to 1.41), fever (RR = 1.31, 95% CI: 0.81 to 2.12), or clinical workups for infection (RR = 1.08, 95% CI: 0.98 to 1.18). A marginally increased risk of outpatient visits in the 7 days postdischarge was detected (RR = 1.13, 95% CI: 1.02 to 1.26). There was no evidence of a substantial increased risk of infection-related outcomes associated with influenza vaccination during hospitalization for orthopaedic surgery. Our data support the recommendation of vaccinating orthopaedic surgery patients against influenza perioperatively.

External Validation and Modification of Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Score.

The Nationwide Inpatient Sample Subarachnoid Hemorrhage (SAH) Severity Score (NIS-SSS) was developed as a measure of SAH severity for use in administrative databases. The NIS-SSS consists of International Classification of Diseases Ninth Revision (ICD-9) diagnostic and procedure codes derived from the SAH inpatient course and has been validated against the Hunt-Hess score (HH). To externally validate both the NIS-SSS and a modified version of the NIS-SSS (m-NIS-SSS) consisting of codes present only on admission, against the HH in a Canadian province-wide registry and administrative database of SAH patients. A total of 1467 SAH patients admitted to Ontario stroke centers between 2003 and 2013 with recorded HH were included. The NIS-SSS and m-NIS-SSS were validated against the HH by testing correlation between the NIS-SSS/m-NIS-SSS and HH, comparing discriminative ability of the NIS-SSS/m-NIS-SSS vs HH for poor outcome by calculating area under the curve (AUC), and comparing calibration of the NIS-SSS, m-NIS-SSS, and HH by plotting predicted vs observed outcome. Correlation with HH was 0.417 (P≤.001) for NIS-SSS, and 0.403 (P≤.001) for m-NIS-SSS. AUC for prediction of poor outcome was 0.786 (0.764-0.808) for HH, 0.771 (0.748-0.793) for NIS-SSS, and 0.744 (0.721-0.767) for m-NIS-SSS. Calibration plots demonstrated that HH had the most accurate prediction of outcome, whereas the NIS-SSS and m-NIS-SSS did not accurately predict low risk of poor outcome. The NIS-SSS and m-NIS-SSS have good external validity, and therefore, may be suitable to approximate traditional clinical scores of disease severity in SAH research using administrative data.

Invasive Staphylococcus aureus Infection among Patients Undergoing Elective, Posterior, Instrumented Spinal Fusion Surgeries: A Retrospective Cohort Study.

Background: Post-surgical invasive Staphylococcus aureus infections among spinal fusion patients are serious complications that can worsen clinical outcomes and increase healthcare utilization. Risk of such infections at the population level remains unknown. This study assessed the post-surgical risk of invasive Staphylococcus aureus infections among patients undergoing elective posterior instrumented spinal fusion surgeries in 129 U.S. hospitals. Patients and Methods: This retrospective cohort study analyzed adult patients ≥18 years of age who underwent thoracolumbar/lumbar and cervical fusion surgeries during 2010 - 2014 using the Premier Healthcare Database, the largest hospital discharge database in the United States. Risks of blood stream infection (BSI), deep or organ/space surgical site infections (SSI) caused by Staphylococcus aureus during 90 and 180 days post-index surgery were estimated. Infections were identified based on positive culture results, related International Classification of Diseases, Ninth Revision (ICD-9) procedure codes, and specific claims information. Results: Among 11,236 patients with thoracolumbar/lumbar fusion, 90- and 180-day BSI/SSI infection risks were higher for multilevel than single level fusion (90-day, 1.52% vs. 1.07%, p = 0.05; 180-day, 1.66% vs. 1.07%, p = 0.014). Among 1,641 patients with cervical fusion, 90- and 180-day BSI/SSI infection risks were also higher in multilevel fusions but not statistically significant (90-day, 1.66% vs. 0.52%, p = 0.350; 180-day, 1.80% vs. 0.51%, p = 0.241). The risk for SSI/BSI was more than twice as high among multilevel thoracolumbar/lumbar fusion patients with more than two comorbidities than those with no comorbidity at both 90-day (2.78% vs. 1.00%, p < 0.05) and 180-day (3.01% vs. 1.10%, p < 0.05). Similar trend without statistical significance was seen in multilevel cervical fusion cohort (90-day, 2.91% vs. 1.25%, p > 0.05; 180-day, 3.88% vs. 1.41%, p > 0.05). Conclusions: The risk of BSI/SSI infection for elective posterior instrumented spinal fusions ranged between 0.5% and 2%. Higher risk was observed in multilevel thoracolumbar/lumbar surgery, with infection risk greatest in patients with more than two comorbidities. These real-world findings highlight the need for additional measures, in addition to antibiotic prophylaxis, to reduce invasive Staphylococcus aureus infections in this setting.

Severe maternal morbidity and mortality during delivery hospitalization of class I, II, III, and super obese women

Previous studies show that obesity predisposes patients to higher risks of adverse pregnancy outcomes. Data on the relationship between increasing degrees of obesity and risks of severe maternal morbidity, including mortality, are limited. We examined the association of increasing classes of obesity, especially super obesity, with the risk of severe maternal morbidity and mortality at the time of delivery hospitalization. Using New York City linked birth certificates and hospital discharge data, we conducted a retrospective cohort study. This study identified delivery hospitalizations for singleton, live births in 2008-2012. Women were classified as having obesity (class I, II, III, or super obesity), as opposed to normal weight or overweight, based on prepregnancy body mass index. Cases of severe maternal morbidity were identified based on International Classification of Diseases, Ninth Revision diagnosis and procedure codes according to Centers for Disease Control and Prevention criteria. Multivariable logistic regression was used to evaluate the association between obesity classes and severe maternal morbidity, adjusting for maternal sociodemographic characteristics. During 2008-2012, there were 570,997 live singleton births with available information on prepregnancy body mass index that met all inclusion criteria. After adjusting for maternal characteristics, women with class II (adjusted odds ratio, 1.14; 95% confidence interval, 1.05-1.23), class III (adjusted odds ratio, 1.34; 95% confidence interval, 1.21-1.49), and super obesity (adjusted odds ratio, 1.99; 95% confidence interval, 1.57-2.54) were all significantly more likely to have severe maternal morbidity than normal and overweight women. Super obesity was associated with specific severe maternal morbidity indicators, including renal failure, air and thrombotic embolism, blood transfusion, heart failure, and the need for mechanical ventilation. There is a significant dose-response relationship between increasing obesity class and the risk of severe maternal morbidity at delivery hospitalization. The risks of severe maternal morbidity are highest for women with super obesity. Given that this is a modifiable risk factor, women with prepregnancy obesity should be counseled on the specific risks associated with pregnancy before conception to optimize their pregnancy outcomes.

Changing trends in Black-White racial differences in surgical menopause: a population-based study

Bilateral oophorectomy before menopause, or surgical menopause, is associated with negative health outcomes, including an increased risk for stroke and other cardiovascular outcomes; however, surgical menopause also dramatically reduces ovarian cancer incidence and mortality rates. Because there are competing positive and negative sequelae associated with surgical menopause, clinical guidelines have not been definitive. Previous research indicates that White women have higher rates of surgical menopause than other racial groups. However, previous studies may have underestimated the rates of surgical menopause among Black women. Furthermore, clinical practice has changed dramatically in the past 15 years, and there are no population-based studies in which more recent data were used. Tracking actual racial differences among women with surgical menopause is important for ensuring equity in gynecologic care. This population-based surveillance study evaluated racial differences in the rates of surgical menopause in all inpatient and outpatient settings in a large, racially diverse US state with historically high rates of hysterectomy. We evaluated all inpatient and outpatient surgeries in North Carolina from 2011 to 2014 for patients aged between 20 and 44 years. Surgical menopause was defined as a bilateral oophorectomy, with or without an accompanying hysterectomy, among North Carolina residents. International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes were used to identify inpatient and outpatient procedures, respectively, and diagnostic indications. We estimated age-, race-, and ethnicity-specific rates of surgical menopause using county-specific population estimates based on the 2010 United States census. We used Poisson regression with deviance-adjusted residuals to estimate the incidence rate ratios in the entire state population. We tested changes in surgery rates over time (reference year, 2011), differences by setting (reference, inpatient), and differences by race and ethnicity (reference, non-Hispanic White). We then described the surgery rates between non-Hispanic White and non-Hispanic Black patients. Between 2011 and 2014, 11,502 surgical menopause procedures for benign indications were performed in North Carolina among reproductive-aged residents. Most (95%) of these surgeries occurred concomitant with a hysterectomy. Over the 4-year study period, there was a 39% reduction in inpatient surgeries (incidence rate ratio, 0.61) and a 100% increase in outpatient surgeries (incidence rate ratio, 2.0). Restricting the analysis to surgeries among non-Hispanic White and Black patients, the increase in outpatient surgeries was significantly higher among non-Hispanic Black women (P<.01) for year-race interaction (reference, 2011 and non-Hispanic White). The overall rates of bilateral oophorectomy for non-Hispanic Black women rose more quickly than for non-Hispanic White women (P<.01). In 2011, the rate of surgical menopause was greater among White women than among Black women (17.7 vs 13.2 per 10,000 women). By 2014, the racial trends were reversed (rate, 24.8 per 10,000 for non-Hispanic White women and 28.4 per 10,000 for non-Hispanic Black women). Our findings suggest that the rates of surgical menopause increased in North Carolina in the early 2010s, especially among non-Hispanic Black women. By 2014, the rates of surgical menopause among non-Hispanic Black women had surpassed that of non-Hispanic White women. Given the long-term health consequences associated with surgical menopause, we propose potential drivers for the racially-patterned increases in the application of bilateral oophorectomy before the age of 45 years.

Higher Patient Complexities are Associated with Increased Length of Stay, Complications, and Readmissions After Total Hip Arthroplasty

Introduction: There is an increased incidence of complex patients undergoing total hip arthroplasty (THA), which demands a rigorous preoperative, intraoperative, and postoperative assessment. It is important how increases in patient complexity impact a variety of patient outcomes. Therefore, the purpose of our study is to determine if a higher Elixhauser Comorbidity Index (ECI), a measure of patient complexity, is correlated with: 1) longer hospital length of stay; 2) increased 90-day medical complications; 3) higher 90-day readmissions; and 4) greater two-year implant-related complications following primary THA. Materials and Methods: Patients undergoing primary THA from January 1, 2004 to December 31, 2015 were queried from the Medicare Standard Analytical Files using the International Classification of Disease, ninth revision (ICD-9) procedure code 81.51. The queried patients (387,831) were filtered by ECI scores of 1 to 5. Patients who have ECI scores of 2 to 5 represented the study cohorts and were matched according to age and sex to patients who have the lowest ECI score (ECI of 1). All cohorts were longitudinally followed to assess and compare hospital length of stay, 90-day medical complications, 90-day readmissions, and two-year implant-related complications. We compared odds-ratios (OR), 95% confidence intervals (95% CI), and p-values using logistic regression analyses and Welch’s t-tests. Results: Patients who have ECI scores greater than 1 had higher hospital length of stay (p&lt;0.001), 90-day medical complications (p&lt;0.001), 90-day readmissions (p&lt;0.001), and two-year implant-related complications (p&lt;0.001). Patients who have an ECI score of 2 (1.26, 95% CI: 1.20–1.32), ECI of 3 (1.61, 95% CI: 1.53–1.69), ECI of 4 (2.05, 95% CI: 1.95–2.14), and ECI of 5 (2.32, 95% CI: 2.21–2.43) had an increasing trend for readmissions, with higher ECI scores correlating with greater odds of readmission following primary THA. Two-year implant-related complications also showed a similar increasing trend with greater patient complexity. Patients who had an ECI score of 5 (2.54, 95% CI: 2.39–2.69) had more implant-related complications compared to patients who had an ECI score of 2 (1.39, 95% CI:1.31–1.48). Conclusion: The results of this study illustrate that a higher Elixhauser-Comorbidity Index is an independent risk factor for longer hospital length of stay, higher 90-day medical complications, greater 90-day readmissions, and increased two-year implant-related complications following primary THA. This study is important as it further defines and heightens awareness of adverse events for complex patients undergoing this procedure. Future studies can examine if these events can potentially be mitigated through reductions in ECI scores prior to surgery and increased incentives for the healthcare team.

Arthroplasty Rates Not Increasing in Young Patients With Rheumatoid Arthritis: A National Database Review, 2005 Versus 2014.

BackgroundFor 20 years, authors have predicted an expansion in total knee arthroplasty (TKA) and total hip arthroplasty (THA) utilization. Over this same period, the introduction of biological disease-modifying antirheumatic drugs has dramatically altered the treatment of rheumatoid arthritis (RA) with hopes of preventing articular damage and obviating the need for prosthetic replacement. The goal of our investigation was to evaluate TKA and THA utilization in young patients with RA (<65 years) in 2005 vs 2014 compared to patients with osteoarthritis (OA).MethodsUsing relevant International Classification of Disease Ninth Revision (ICD-9) and Current Procedural Terminology codes, the Truven MarketScan Database (over 46 million enrollees) was queried to determine THA and TKA incidence rates for RA and OA patients aged <65 years during the final decade of ICD-9 use. Patients with potentially confounding ICD-9 codes were excluded to limit coding variation. Statistical analysis consisted of student t-tests, Pearson's chi-square tests, and Breslow-Day tests.ResultsFor patients with OA, TKAs increased substantially from 0.07% in 2005 to 0.1% in 2014 (+42.9% change, P < .001). Similarly for patients with OA, THAs increased from 0.04% to 0.06% over the same time period (+66.0% change, P < .001). For young patients with RA, the rate of TKA remained relatively stable—1.06% in 2005 to 1.04% in 2014 (−1.7% change, P = .65)—as did THA—0.44% to 0.48% (+9.0% change, P = .14).ConclusionsDramatic increases in THA and TKA rates for OA patients aged <65 years were indeed observed from 2005 to 2014. This trend, however, was not seen in the RA population where TKA and THA rates remained unchanged.

Impact of Biological Sex on Complications, Lengths of Stay, Readmission Rates, and Costs of Care Following Primary Total Knee Arthroplasty.

The impact of gender on total knee arthroplasty (TKA) postoperative complications, readmission rates, and costs of care has not been often evaluated. Therefore, the purpose of this study was to investigate which sex had higher rates of: (1) medical complications; (2) implant complications; (3) lengths of stay (LOSs); (4) readmission rates; and (5) costs after TKA. A query was performed using an administrative claims database from January 1, 2005, to March 31, 2015. Patients who had TKAs were identified using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Males and females were filtered separately and matched according to age and various medical comorbidities leading to 1,590,626 patients equally distributed. Primary outcomes analyzed included 90-day medical complications, LOSs, 90-day readmission rates, in addition to day of surgery and total global 90-day episode of care costs. Pearson's chi-square analyses were used to compare medical complications and readmission rates. Welch's t-tests were used to test for significance in matching outcomes and costs. A p-value of less than 0.01 was considered statistically significant. Males had a smaller risk of complications than women (1.35 vs. 1.40%, p < 0.006) and higher rates of implant-related complications (2.28 vs. 1.99%, p < 0.0001). Mean LOSs were lower for males: 3.16 versus 3.34 days (p < 0.0001). The 90-day readmission rates were higher in men (9.67 vs. 8.12%, p < 0.0001). This study demonstrated that males undergoing primary TKA have lower medical complications and shorter LOSs then their female counterparts. However, males have higher implant-related complications, readmission rates, and costs of care.