Skip to main content
Hauptrubriken
CME Facharzt-Training Webinare Zeitschriften Bücher e.Medpedia Podcast
Service
Jobbörse Info & Hilfe
Fachgebiete
Anästhesiologie Allgemeinmedizin Arbeitsmedizin Augenheilkunde Chirurgie Dermatologie Gynäkologie und Geburtshilfe HNO Innere Medizin Kardiologie Neurologie Onkologie und Hämatologie Orthopädie und Unfallchirurgie Pädiatrie Pathologie Psychiatrie Radiologie Rechtsmedizin Urologie Zahnmedizin
Themen
Typ-2-Diabetes und Adipositas Klimawandel und Gesundheit Neues aus dem Markt Praxis und Beruf Seltene Erkrankungen GOÄ & EBM Panorama
Sammlungen
Kasuistiken Algorithmen & Infografiken Blickdiagnosen Arthropedia FlapFinder (für Dermatochirurgen) Videos Kongressberichterstattung Medizin für Apothekerinnen und Apotheker Für Ärztinnen und Ärzte in Weiterbildung Für Medizinstudierende Patientenratgeber
Erweiterte Suche
Anmelden
nach oben
Current Reviews in Musculoskeletal Medicine
Erschienen in:

28.07.2017 | Quality and Cost Control in TJA (B Waddell, section editor)

Improving Quality and Decreasing Cost by Reducing Re-admissions in Patients Undergoing Total Joint Arthroplasty

verfasst von: Daniel S. Sveom, Mary K. Otteman, Kevin L. Garvin

Erschienen in: Current Reviews in Musculoskeletal Medicine | Ausgabe 3/2017

Einloggen, um Zugang zu erhalten

Abstract

Purpose of review

Total joint arthroplasty (TJA) has had an increased demand over the recent years. It is a successful procedure, and there are relatively few complications, but there is a high overall cost. There is a push to increase the quality of care, lessen complications, and decrease cost by reducing readmissions. This article will discuss the risk factors that can contribute to the complication and readmission rates following TJA.

Recent findings

Several risk factors have been found to contribute to the complication and readmission rates following a TJA. It is important to understand these risk factors and mitigate them as much as possible in order to optimize the patient experience. There are risk factors that cannot be modified, and the treatment team as well as the patient should be made aware of these and account for them when making the decision whether to undergo elective primary TJA or not. In general, an increased number of risk factors is associated with increased complications and increased readmission rates. At our institution, we have used this knowledge to improve our outcomes and decrease costs.

Summary

It is important to be mindful of risk factors for poor outcomes prior to performing TJA. This allows for the optimization of patients prior to undergoing surgery. This can lead to improved outcomes at a lower cost.
Literatur
1.
• Maoz G, Phillips M, Bosco J, Slover J, Stachel A, Inneh I, et al. The Otto Aufranc Award: modifiable versus nonmodifiable risk factors for infection after hip arthroplasty. Clin Orthop Relat Res. 473(2):453–9. This paper reviewed the characteristics 3672 primary and 406 revision hip arthroplasties performed over a 3-year period at a single specialty hospital. There was a rate of 1.3% deep prosthetic joint infections over that time period. The authors evaluated the results to determine modifiable and non-modifiable risk factors for prosthetic joint infection. Non-modifiable risk factors include nonsame-day hip and revision arthroplasties. Modifiable risk factors include operating time, elevated BMI, tobacco use, and S aureus colonization. The authors determined that modifying risk factors may reduce the incidence of prosthetic joint infections.
2.
• Iorio R, Osmani FA. Strategies to prevent periprosthetic joint infection after total knee arthroplasty and lessen the risk of readmission for the patient. J Am Acad Orthop Surg. 2017;25(Suppl 1):S13–6. This is a review paper that discusses known risk factors for prosthetic joint infection after total knee arthroplasty and how to reduce the risk of readmission post-operatively. Risk factors discussed includes S aureus colonization, hepatitis C and HIV infection, tobacco use, obesity and malnutrition, neurocognitive problems, drug abuse, alcohol abuse, diabetes complications and nutritional deficiencies. The authors also discussed areas of investigation which require more research including, patient optimization, perioperative antibiotics, OR environment, VTED management, operative techniques, wound management, and post-acute care.
3.
4.
Biener A, Cawley J, Meyerhoefer C. The high and rising costs of obesity to the US health care system. J Gen Intern Med. 2017 Apr;32(Suppl 1):6–8.CrossRefPubMed
5.
6.
Kerkhoffs GM, Servien E, Dunn W, Dahm D, Bramer JA, Haverkamp D. The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review. J Bone Joint Surg Am. 2012 Oct 17;94(20):1839–44.CrossRefPubMedPubMedCentral
7.
Alvi HM, Mednick RE, Krishnan V, Kwasny MJ, Beal MD, Manning DW. The effect of BMI on 30 day outcomes following total joint arthroplasty. J Arthroplast. 2015 Jul;30(7):1113–7.CrossRef
8.
Severson EP, Singh JA, Browne JA, Trousdale RT, Sarr MG, Lewallen DG. Total knee arthroplasty in morbidly obese patients treated with bariatric surgery: a comparative study. J Arthroplast. 2012;27(9):1696–700.CrossRef
9.
10.
Bolognesi MP, Marchant MH Jr, Viens NA, Cook C, Pietrobon R, Vail TP. The impact of diabetes on perioperative patient outcomes after total hip and total knee arthroplasty in the United States. J Arthroplast. 2008 Sep;23(6 Suppl 1):92–8.CrossRef
11.
12.
Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009;91(7):1621–9.CrossRefPubMed
13.
Adams AL, Paxton EW, Wang JQ, Johnson ES, Bayliss EA, Ferrara A, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009. J Bone Joint Surg Am. 2013;95(6):481–7.CrossRefPubMed
14.
Sudhakaran S, Surani SR. Guidelines for perioperative management of the diabetic patient. Surg Res Pract. 2015;2015:284063.PubMedPubMedCentral
15.
Courtney PM, Rozell JC, Melnic CM, Sheth NP, Nelson CL. Effect of malnutrition and morbid obesity on complication rates following primary total joint arthroplasty. J Surg Orthop Adv. 2016;25(2):99–104.CrossRefPubMed
16.
• Fu MC, McLawhorn AS, Padgett DE, Cross MB. Hypoalbuminemia is a better predictor than obesity of complications after total knee arthroplasty: a propensity score-adjusted observational analysis. HSS J. 2017;13(1):66–74. This study examined the prevalence of hypoalbuminemia in obese patients undergoing total knee arthroplasty and the independent morbidity risk of malnutrition relative to obesity. Malnutrition was defined as hypoalbuminemia (3.5 g/dL). The BMI classifications used in this study were non-obese (18.5-29.9), obese I (30-34.9), obese II (35-39.9), and obese III (>40). The prevalence of malnutrition increased with BMI (6.1% in obese III vs. 3.7% in non-obese). Obese III was the only obesity class associated with any complication, wound complication, and reoperation. Hypoalbuminemia was found to be a stronger and more consistent independent risk factor, for any complication, wound, cardiac, or respiratory complications, and death.
17.
Yu S, Garvin KL, Healy WL, Pellegrini VD Jr, Iorio R. Preventing hospital readmissions and limiting the complications associated with Total joint arthroplasty. J Am Acad Orthop Surg. 2015;23(11):e60–71.CrossRefPubMed
18.
689Enhanced Detection of Staphylococcus aureus Colonization in Patients Undergoing Total Joint Arthroplasty. Open Forum Infectious Diseases: Oxford University Press; 2014.
19.
Courville XF, Tomek IM, Kirkland KB, Birhle M, Kantor SR, Finlayson SR. Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis. Infect Control Hosp Epidemiol. 2012;33(2):152–9.CrossRefPubMed
20.
Singh JA, Houston TK, Ponce BA, Maddox G, Bishop MJ, Richman J, et al. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis Care Res (Hoboken). 2011;63(10):1365–74.CrossRef
21.
Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br. 2003;85(2):178–81.CrossRefPubMed
22.
Lavernia CJ, Sierra RJ, Gomez-Marin O. Smoking and joint replacement: resource consumption and short-term outcome. Clin Orthop Relat Res. 1999 ;(367):172–180.
23.
Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359(9301):114–7.CrossRefPubMed
24.
Sheth NP, Lieberman JR, Della Valle CJ. DVT prophylaxis in total joint reconstruction. Orthop Clin North Am. 2010;41(2):273–80.CrossRefPubMed
25.
Lieberman JR. American College of Chest Physicians evidence-based guidelines for venous thromboembolic prophylaxis: the guideline wars are over. J Am Acad Orthop Surg. 2012;20(6):333–5.CrossRefPubMed
26.
Ackland GL, Harris S, Ziabari Y, Grocott M, Mythen M, SOuRCe Investigators. Revised cardiac risk index and postoperative morbidity after elective orthopaedic surgery: a prospective cohort study. Br J Anaesth 2010;105(6):744–752.
27.
Urban MK, Markowitz SM, Gordon MA, Urquhart BL, Kligfield P. Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg. 2000;90(6):1257–61.CrossRefPubMed
28.
Ayers DC, Franklin PD, Trief PM, Ploutz-Snyder R, Freund D. Psychological attributes of preoperative total joint replacement patients: implications for optimal physical outcome. J Arthroplast. 2004;19(7 Suppl 2):125–30.CrossRef
29.
Witvrouw E, Pattyn E, Almqvist KF, Crombez G, Accoe C, Cambier D, et al. Catastrophic thinking about pain as a predictor of length of hospital stay after total knee arthroplasty: a prospective study. Knee Surg Sports Traumatol Arthrosc. 2009;17(10):1189–94.CrossRefPubMed
30.
Berge DJ, Dolin SJ, Williams AC, Harman R. Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial. Pain. 2004 Jul;110(1–2):33–9.CrossRefPubMed
31.
Keefe FJ, Caldwell DS, Williams DA, Gil KM, Mitchell D, Robertson C, et al. Pain coping skills training in the management of osteoarthritic knee pain: a comparative study. Behav Ther. 1990;21(1):49–62.CrossRef
32.
Carpenter I, Bobby J, Kulinskaya E, Seymour G. People admitted to hospital with physical disability have increased length of stay: implications for diagnosis related group re-imbursement in England. Age Ageing. 2007;36(1):73–8.CrossRefPubMed
33.
• Snow R, Granata J, Ruhil AV, Vogel K, McShane M, Wasielewski R. Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement. J Bone Joint Surg Am. 2014;96(19):e165. This study investigated the associations or preoperative physical therapy and post-acute care resource use and its effect on the total cost of care during primary hip or knee arthroplasty. The authors found that the use of preoperative physical therapy was associated with a 29% decrease in the use of any post-acute care services. The use of preoperative physical therapy also lead to an $871 reduction of episode payment, driven largely by a reduction in payments for skilled nursing facility, home health agency, and inpatient rehabilitation.
34.
• Boraiah S, Joo L, Inneh IA, Rathod P, Meftah M, Band P, et al. Management of modifiable risk factors prior to primary hip and knee arthroplasty: a readmission risk assessment tool. J Bone Joint Surg Am. 2015;97(23):1921–8. This paper outlined the Readmission Risk Assessment Tool (RRAT) used at NYU Langone Medical Center Hospital for Joint Diseases. The RRAT allows for risk stratification in patients undergoing elective primary total joint arthroplasty. An RRAT score of 3 or greater was significantly associated with higher odds of readmission. The authors concluded that the RRAT could be a clinically useful tool for risk mitigation.
35.
Malkani AL, Dilworth B, Ong K, Baykal D, Lau E, Mackin TN, et al. High risk of readmission in octogenarians undergoing primary hip arthroplasty. Clin Orthop Relat Res. 2017.
36.
Singh JA, Kwoh CK, Richardson D, Chen W, Ibrahim SA. Sex and surgical outcomes and mortality after primary total knee arthroplasty: a risk-adjusted analysis. Arthritis Care Res (Hoboken). 2013;65(7):1095–102.CrossRef
37.
• Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis. 2014;73(12):2107–15. This study examined whether racial disparities in usage and outcomes of total knee and total hip arthroplasty have declined over time. This was accomplished by analyzing data from the US Medicare Program for years 1991-2008. Based on their data analysis, the authors concluded that there has been little evidence of declines in racial disparities for joint arthroplasty usage or outcomes.
38.
Keeney JA, Nam D, Johnson SR, Nunley RM, Clohisy JC, Barrack RL. Socioeconomically disadvantaged CMS beneficiaries do not benefit from the readmission reduction initiatives. J Arthroplast. 2015;30(12):2082–5.CrossRef
39.
Gold HT, Slover JD, Joo L, Bosco J, Iorio R, Oh C. Association of depression with 90-day hospital readmission after total joint arthroplasty. J Arthroplast. 2016;31(11):2385–8.CrossRef
40.
Klement MR, Nickel BT, Penrose CT, Bala A, Green CL, Wellman SS, et al. Psychiatric disorders increase complication rate after primary total knee arthroplasty. Knee. 2016;23(5):883–6.CrossRefPubMed
41.
• Tan TL, Kheir MM, Tan DD, Filippone EJ, Tischler EH, Chen AF. Chronic kidney disease linearly predicts outcomes after elective total joint arthroplasty. J Arthroplasty. 2016;31(9 Suppl):175–9. e2 This study examined the association between the chronic kidney disease staging system with complications after total joint arthroplasty. The authors found that CKD stage greater than 2 demonstrated an increased risk of receiving transfusion, increased length of stay, acute kidney injury, septic revisions, and in-hospital complications. The relationship between eGFR and complications increased linearly rather than demonstrating a clear threshold at which the risk increased substantially.
42.
• Bohl DD, Saltzman BM, Sershon RA, Darrith B, Okroj KT, Della Valle CJ. Incidence, Risk Factors, and Clinical Implications of Pneumonia Following Total Hip and Knee Arthroplasty. J Arthroplasty. 2017. This study examined the incidence, risk factors, and clinical implications of pneumonia within 30 days after total joint arthroplasty. The incidence of pneumonia in this study was 0.34%. The risk factors included chronic obstructive pulmonary disease, diabetes mellitus, age >80 years old, dyspnea on exertion, dependent functional status, lower body mass index, hypertension, current smoker status, and male sex. Patients who developed pneumonia were more likely to have a higher readmission rate and a higher mortality rate. 80% of patients who developed pneumonia were readmitted and 3.7% died.
43.
Ricciardi BF, Oi KK, Daines SB, Lee YY, Joseph AD, Westrich GH. Patient and perioperative variables affecting 30-day readmission for surgical complications after hip and knee arthroplasties: a matched cohort study. J Arthroplast. 2017;32(4):1074–9.CrossRef
44.
Kurtz SM, Lau ED, Ong KL, Adler EM, Kolisek FR, Manley MT. Which hospital and clinical factors drive 30- and 90-day readmission after TKA. J Arthroplast. 2016;31:2099–107.CrossRef
45.
Varacallo MA, Herzog L, Toossi N, Johanson NA. Ten-year trends and independent risk factors for unplanned readmission following elective total joint arthroplasty at a large urban academic hospital. J Arthroplast. 2016;32:1739–46.CrossRef
46.
Williams J, Kester BS, Bosco JA, Slover JD, Iorio R, Schwarzkopf R. The association between hospital length of stay and 90-day readmission risk within a total joint arthroplasty bundled payment initiative. J Arthroplast. 2016;32:714–8.CrossRef
47.
Fu MC, Samuel AM, Sculco PK, Maclean CH, Padgett DE, McLawhorn AS. Discharge to inpatient facilities after total hip arthroplasty is associated with increased postdischarge morbidity. J Arthroplast. 2017:1–6.
Metadaten
Titel
Improving Quality and Decreasing Cost by Reducing Re-admissions in Patients Undergoing Total Joint Arthroplasty
verfasst von
Daniel S. Sveom
Mary K. Otteman
Kevin L. Garvin
Publikationsdatum
28.07.2017
Verlag
Springer US
Erschienen in
Current Reviews in Musculoskeletal Medicine / Ausgabe 3/2017
Elektronische ISSN: 1935-9748
DOI
https://doi.org/10.1007/s12178-017-9424-5

Weitere Artikel der Ausgabe 3/2017

ACL Injury Prevention: What Does Research Tell Us?

  • ACL Rehab (T Sgroi and J Molony, section editors)

ACL Rehabilitation Progression: Where Are We Now?

  • ACL Rehab (T Sgroi and J Molony, section editors)

Preoperative Education for Hip and Knee Replacement: Never Stop Learning

  • Open Access
  • Quality and Cost Control in TJA (B Waddell, section editor)

Current Trends in Discharge Disposition and Post-discharge Care After Total Joint Arthroplasty

  • Quality and Cost Control in TJA (B Waddell, section editor)

Prevention and Management of Post-operative Complications Following ACL Reconstruction

  • ACL Rehab (T Sgroi and J Molony, section editors)

Technology in Arthroplasty: Are We Improving Value?

  • Quality and Cost Control in TJA (B Waddell, section editor)

Arthropedia

Grundlagenwissen der Arthroskopie und Gelenkchirurgie erweitert durch Fallbeispiele, Videos und Abbildungen. Zur Fortbildung und Wissenserweiterung, verfasst und geprüft von Expertinnen und Experten der Gesellschaft für Arthroskopie und Gelenkchirurgie (AGA).


Jetzt entdecken!

Neu im Fachgebiet Orthopädie und Unfallchirurgie

Leitlinienkonformes Management thermischer Verletzungen

Thermische Verletzungen gehören zu den schwerwiegendsten Traumen und hinterlassen oft langfristige körperliche und psychische Spuren. Die aktuelle S2k-Leitlinie „Behandlung thermischer Verletzungen im Kindesalter (Verbrennung, Verbrühung)“ bietet eine strukturierte Übersicht über das empfohlene Vorgehen.

Positive Daten für supraskapulären Nervenblock bei Schultersteife

Daten einer aktuellen Metaanalyse sprechen dafür, dass eine Blockade des Nervus suprascapularis bei Schultersteife mit Blick auf Funktion und Schmerzlinderung mindestens so effektiv ist wie eine Physiotherapie oder intraartikulär injizierte Steroide.

Wirbelgleiten: Dem persönlichen Drang zum Versteifen widerstehen!

In einer norwegischen Studie schnitt die alleinige Dekompressions-Op. bei Personen mit Wirbelgleiten auch dann nicht schlechter ab, wenn erfahrene Chirurgen/ Chirurginnen eigentlich für eine zusätzliche Versteifung plädiert hätten.

Nackenschmerzen nach Bandscheibenvorfall: Muskeltraining hilft!

Bei hartnäckigen Schmerzen aufgrund einer zervikalen Radikulopathie schlägt ein Team der Universität Istanbul vor, lokale Steroidinjektionen mit einem speziellen Trainingsprogramm zur Stabilisierung der Nackenmuskulatur zu kombinieren.

Update Orthopädie und Unfallchirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen
Bildnachweise