Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Mental Health and Housing Status-Part Five of the Movement Is Life Special ONJ Series.

Mental health and housing status have the potential to impact total joint arthroplasty (TJA) outcomes and are common TJA eligibility criteria that prevent patients from receiving surgery. Our aim was to formulate recommendations for how nurse navigators can assist patients with managing mental health and housing concerns. Through discussions with nurse navigators and a literature search across two databases, we gathered information regarding the optimization of mental health and housing status among TJA patients. We observed a lack of standardized protocols for addressing these concerns and literature supporting an increased focus on mental health and housing status, indicating the potential for greater nurse navigator involvement in developing and implementing protocols. We recommend nurse navigators use screening tools to identify mental health and housing concerns and offer the suggested resources to support patients in an effort to improve postoperative outcomes and decrease surgical risks.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Obesity and Malnutrition-Part Four of the Movement Is Life Special ONJ Series.

Obesity and malnutrition affect many patients with osteoarthritis and can predispose patients to worse outcomes after total joint arthroplasty (TJA). However, these modifiable risk factors can be addressed in preoperative optimization programs driven by nurse navigators. Our aim is to provide resources and recommendations for nurse navigators when addressing obesity and malnutrition among TJA patients. In addition to discussions with nurse navigators regarding obesity and malnutrition, a literature review was conducted to assess the current practice standards for management. Nurse navigators often had difficulty implementing long-term interventions, but interventions in the literature included medical and bariatric treatments for obesity and more targeted assessment of nutrition status. These findings are incorporated into our recommendations for nurse navigators. Addressing obesity and malnutrition in preoperative optimization can contribute to improved outcomes, as has been demonstrated in current practice and in the literature.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Diabetes and Cardiovascular Disease-Part 3 of the Movement Is Life Special ONJ Series.

Diabetes and cardiovascular disease are some of the most common risk factors for complications after total joint arthroplasty (TJA). Preoperative optimization programs are dependent on nurse navigators for coordination of interventions that improve patients' health and surgical outcomes. This article uses information regarding the current practices for diabetes and cardiovascular disease management to provide recommendations for nurse navigators when managing these risk factors prior to TJA. We consulted nurse navigators and conducted a literature review to learn about strategies for addressing diabetes and cardiovascular disease in preoperative optimization programs. Nurse navigators can play a critical role in addressing these conditions by providing patient education and implementing preoperative optimization protocols that incorporate discussion regarding guidelines for diabetes and cardiovascular disease management prior to surgery. This article shares recommendations and resources for nurse navigators to help address diabetes and cardiovascular disease as part of preoperative optimization programs.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Substance Use.

Substance use is one of the most common risk factors contributing to complications following total joint arthroplasty. Preoperative optimization programs can help patients modify or stop substance use. The purpose of this study was to provide recommendations and resources that will help nurse navigators standardize and improve preoperative optimization protocols regarding substance use. In a semistructured format, we asked nurse navigators how smoking, alcohol use, and opioid use were addressed. We conducted a literature review and combined findings with nurse navigator reports to create practice recommendations. We recommend consistently referring patients who smoke to smoking cessation programs; using validated screening tools to evaluate alcohol use and involving internists in caring for patients at risk for withdrawal; and involving pain specialists and local resources to assist patients who use opioids. There is a breadth of resources for managing substance use that nurse navigators can utilize to support stronger and more consistent preoperative optimization protocols.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Improving Patient Access to Musculoskeletal Care.

Preoperative optimization programs for total joint arthroplasty identify and address risk factors to reduce postoperative complications, thereby improving patients' ability to be safe surgical candidates. This article introduces preoperative optimization programs and describes the role of orthopaedic nurse navigators. This foundation will be used to produce an article series with recommendations for optimization of several modifiable biopsychosocial factors. We consulted orthopaedic nurse navigators across the United States and conducted a literature review regarding preoperative optimization to establish the importance of nurse navigation in preoperative optimization. The responsibilities of nurse navigators, cited resources, and structure of preoperative optimization programs varied among institutions. Optimization programs relying on nurse navigators frequently demonstrated improved outcomes. Our discussions and literature review demonstrated the integral role of nurse navigators in preoperative optimization. We will discuss specific risk factors and how nurse navigators can manage them throughout this article series.

Metrics for Monitoring Preoperative Optimization Programs for Total Joint Arthroplasty: A Survey of Orthopaedic Nurses.

Preoperative optimization programs are becoming more common for patients seeking total joint arthroplasty; yet, limited research has been conducted to monitor the long-term effects of these programs on patient outcomes. Our aim was to develop a set of metrics that programs can use to monitor the success of preoperative optimization programs. As part of a larger survey of orthopaedic nurses, we collected data regarding current monitoring techniques for preoperative optimization programs and the feasibility of collecting specific variables. Surgical factors such as length of stay and 30-day readmissions were most often used to monitor the success of preoperative optimization programs. Surgical factors were the most likely to be accessible using the electronic medical record. Surgical factors and patient characteristics are the most feasible components for programs to monitor in order to track the outcomes of patients participating in preoperative optimization programs.

The Use of Risk Scores in Patient Preoperative Optimization for Total Joint Arthroplasty: A Survey of Orthopaedic Nurse Navigators.

Preoperative optimization of patients seeking total joint arthroplasty is becoming more common, and risk scores, which provide an estimate for the risk of complications following procedures, are often used to assist with the preoperative decision-making process. The aim of this study was to characterize the use of risk scores at institutions that utilize nurse navigators in the preoperative optimization process. The survey included 207 nurse navigators identified via the National Association of Orthopaedic Nurses to better understand the use of risk scores in preoperative optimization and the different factors that are included in these risk scores. The study found that 48% of responding nurse navigators utilized risk scores in the preoperative optimization process. These risk scores often included patient comorbidities such as diabetes (85%) and body mass index (87%). Risk scores are commonly used by nurse navigators in preoperative optimization and involve a variety of comorbidities and patient-specific factors.

Characterizing the lack of diversity in musculoskeletal urgent care website content.

BACKGROUND: Musculoskeletal urgent care centers (MUCCs) are becoming an alternative to emergency departments for non-emergent orthopedic injuries as they can provide direct access to orthopedic specialty care. However, they tend to be located in more affluent geographies and are less likely to accept Medicaid insurance than general urgent care centers. MUCCs utilize websites to drive patients to their centers, and the content may influence patients' consumer behaviors and perceptions of the quality and accessibility of the MUCCs. Given that some MUCCs target insured patient populations, we evaluated the racial, gender, and body type diversity of website content for MUCCs. METHODS: Our group conducted an online search to create a list of MUCCs in the United States. For each MUCC, we analyzed the content featured prominently on the website (above the fold). For each website, we analyzed the race, gender, and body type of the featured model(s). MUCCs were classified according to their affiliation (i.e. academic versus private) and region (i.e. Northeast versus South). We performed chi-squared and univariate logistic regression to investigate trends in MUCC website content. RESULTS: We found that 14% (32/235) of website graphics featured individuals from multiple racial groups, 57% (135/235) of graphics featured women, and 2% (5/235) of graphics featured overweight or obese individuals. Multiracial presence in website graphics was associated with the presence of women on the websites and Medicaid acceptance. CONCLUSION: MUCC website content has the potential to impact patients' perceptions of medical providers and the medical care they receive. Most MUCC websites lack diversity based on race and body type. The lack of diversity in website content at MUCCs may introduce further disparities in access to orthopedic care.

Orthopaedic Nurse Navigator Involvement in Preoperative Optimization for Total Joint Arthroplasty.

Patients seeking total joint arthroplasty frequently undergo preoperative optimization with the assistance of nurse navigators to facilitate interactions between patients, consulting services, and the orthopaedic surgical team. Given the enormous impact nurse navigator programs have on reducing postoperative complications, our aim is to characterize the involvement of nurse navigators in preoperative optimization programs across the country. We conducted a survey of nurse navigators identified through the National Association of Orthopaedic Nurses to assess the involvement of nurse navigators in the preoperative optimization process. Sixty-seven percent of responding nurse navigators were involved in preoperative optimization, including components such as heart disease (53%) and poorly controlled diabetes (52%). Orthopaedic nurse navigators are commonly involved in preoperative optimization programs for total joint arthroplasty but most of these involve gated yes/no checklists with limited established referral care pathways. Only some of the programs include standardized referrals for specific medical comorbidities.

Preoperative Risk Management Programs at the Top 50 Orthopaedic Institutions Frequently Enforce Strict Cutoffs for BMI and Hemoglobin A1c Which May Limit Access to Total Joint Arthroplasty and Provide Limited Resources for Smoking Cessation and Dental Care.

BACKGROUND: Performing elective orthopaedic surgery on patients with high BMI, poorly controlled hyperglycemia, and who use tobacco can lead to serious complications. Some surgeons use cutoffs for BMI, hemoglobin A1c, and cigarette smoking to limit surgery to patients with lower risk profiles rather than engaging in shared decision-making with patients about those factors. Other studies have suggested this practice may discriminate against people of lower income levels and women. However, the extent to which this practice approach is used by orthopaedic surgeons at leading hospitals is unknown. QUESTIONS/PURPOSES: (1) How often are preoperative cutoffs for hemoglobin A1c and BMI used at the top US orthopaedic institutions? (2) What services are available at the top orthopaedic institutions for weight loss, smoking cessation, and dental care? (3) What proportion of hospital-provided weight loss clinics, smoking cessation programs, and dental care clinics accept Medicaid insurance? METHODS: To investigate preoperative cutoffs for hemoglobin A1c and BMI and patient access to nonorthopaedic specialists at the top orthopaedic hospitals in the United States, we collected data on the top 50 orthopaedic hospitals in the United States as ranked by the 2020 US News and World Report 's "Best Hospitals for Orthopedics" list. We used a surgeon-targeted email survey to ascertain information regarding the use of preoperative cutoffs for hemoglobin A1c and BMI and availability and insurance acceptance policies of weight loss and dental clinics. Surgeons were informed that the survey was designed to assess how their institution manages preoperative risk management. The survey was sent to one practicing arthroplasty surgeon, the chair of the arthroplasty service, or department chair, whenever possible, at the top 50 orthopaedic institutions. Reminder emails were sent periodically to encourage participation from nonresponding institutions. We received survey responses from 70% (35 of 50) of hospitals regarding the use of preoperative hemoglobin A1c and BMI cutoffs. There was no difference in the response rate based on hospital ranking or hospital region. Fewer responses were received regarding the availability and Medicaid acceptance of weight loss and dental clinics. We used a "secret shopper" methodology (defined as when a researcher calls a facility pretending to be a patient seeking care) to gather information from hospitals directly. The use of deception in this study was approved by our institution's institutional review board. We called the main telephone line at each institution and spoke with the telephone operator at each hospital asking standardized questions regarding the availability of medical or surgical weight loss clinics, smoking cessation programs, and dental clinics. When possible, researchers were referred directly to the relevant departments and asked phone receptionists if the clinic accepted Medicaid. We were able to contact every hospital using the main telephone number. Our first research question was answered using solely the surgeon survey responses. Our second and third research questions were addressed using a combination of the responses to the surgeon surveys and specific hospital telephone calls. RESULTS: Preoperative hemoglobin A1c cutoffs were used at 77% (27 of 35) of responding institutions and preoperative BMI cutoffs were used at 54% (19 of 35) of responding institutions. In the secret shopper portion of our study, we found that almost all the institutions (98% [49 of 50]) had a medical weight loss clinic, surgical weight loss clinic, or combined program. Regarding smoking cessation, 52% (26 of 50) referred patients to a specific department in their institution and 18% (9 of 50) referred to a state-run smoking cessation hotline. Thirty percent (15 of 50) did not offer any internal resource or external referral for smoking cessation. Regarding dental care, 48% (24 of 50) of institutions had a dental clinic that performed presurgical check-ups and 46% (23 of 50) did not offer any internal resource or external referral for dental care. In the secret shopper portion of our study, for institutions that had internal resources, we found that 86% (42 of 49) of weight loss clinics, 88% (23 of 26) of smoking cessation programs, and 58% (14 of 24) of dental clinics accepted Medicaid insurance. CONCLUSION: Proceeding with TJA may not be the best option for all patients; however, surgeons and patients should come to this consensus together after a thoughtful discussion of the risks and benefits for that particular patient. Future research should focus on how shared decision-making may influence patient satisfaction and a patient's ability to meet preoperative goals related to weight loss, glycemic control, smoking cessation, and dental care. Decision analyses or time trade-off analyses could be implemented in these studies to assess patients' tolerance for risk. CLINICAL RELEVANCE: Orthopaedic surgeons should engage in shared decision-making with patients to develop realistic goals for weight loss, glycemic control, smoking cessation, and dental care that consider patient access to these services as well as the difficulties patients experience in losing weight, controlling blood glucose, and stopping smoking.

The Use of Race in Risk Assessment Tools Contributes to Systemic Racism.

Many patients suffer from hip or knee osteoarthritis and elect to pursue total joint arthroplasty (TJA). Though perioperative risk is an inherent component of surgery, calculators that assess the risk of complications following TJA can help both surgeons and patients make informed decisions about the risk of surgery and aid in shared decision-making discussions. The inclusion of race in a risk calculator for readmission after TJA is flawed and unacceptable because a patient's race does not increase their risk of a complication after total joint replacement.

Evaluating musculoskeletal urgent care center triage and transfer of emergency conditions for emergency surgical assessment and intervention.

Musculoskeletal urgent care centers (MUCCs) are an alternative to emergency departments (EDs) for patients to seek care for low acuity orthopedic injuries such as ankle sprains or joint pain, but are not equipped to manage orthopedic emergencies that require a higher level of care provided in the ED. This study aims to evaluate telephone and online triage practices as well as ED transfer procedures for MUCCs for patients presenting with an orthopedic condition requiring urgent surgical intervention. We called 595 MUCCs using a standardized script presenting as a critical patient with symptoms of lower extremity compartment syndrome. We compared direct ED referral frequency and triage frequency for MUCCs for patients insured by either Medicaid or by private insurance. We found that patients presenting with an apparent compartment syndrome were directly referred to the ED by < 1 in 5 MUCCs. Additionally, < 5% of patients were asked additional triage questions that would increase clinician suspicion for compartment syndrome and allow MUCCs to appropriately direct patients to the ED. MUCCs provide limited telephone and online triage for patients, which may result in delays of care for life or limb threatening injuries that require ED resources such as sedation, reductions, and emergency surgery. However, when MUCCs did conduct triage, it significantly increased the likelihood that patients were appropriately referred to the ED. Level of Evidence: Level II, prognostic study.

Intersectionality of Net Worth and Race Relative to Utilization of Total Hip and Knee Arthroplasty.

BACKGROUND: Although the number of total hip arthroplasty and total knee arthroplasty (THA and TKA) increases, individuals of color continue to be less likely to undergo these procedures. Socioeconomic status may be a key influencer of THA and TKA utilization and outcomes. We explore the influence of net worth and race on THA and TKA utilization and outcomes of length of stay and readmissions using a large patient database. METHODS: The StrataSphere data set, an aggregation of 49 health systems representing 209 hospitals, was used for primary THA and TKA procedures performed in the calendar year 2019. Net worth was determined from Market Vue Partners' data sources. Statistical analyses were performed to investigate relationships between net worth and patients undergoing THA or TKA. RESULTS: When comparing our overall patient cohorts with the US population using Census data, we found differences in the utilization pattern indicated by index ratios most clearly in the lowest net worth categories. In the <$10K net worth category, THA and TKA index ratios were 0.51 and 0.54, respectively. In addition, we found that patients in the $100-250 and $250-500K net worth categories had increased utilization of both THA (index ratios of 1.39, 1.53) and TKA (index ratios of 1.45, 1.47) surgeries. CONCLUSION: Net worth is a strong driver of disparities in utilization of THA and TKA with lower utilization of these surgeries in patients with net worth <$10K and increased utilization in patients with net worth from $100-250 and $250-500K.

Preoperative Risk Factor Optimization Lowers Hospital Length of Stay and Postoperative Emergency Department Visits in Primary Total Hip and Knee Arthroplasty Patients.

BACKGROUND: The evaluation and management of outcomes risk has become an essential element of a modern total joint replacement program. Our multidisciplinary team designed an evidence-based tool to address modifiable risk factors for adverse outcomes after primary hip and knee arthroplasty surgery. METHODS: Our protocols were designed to identify, intervene, and mitigate risk through evidence-based patient optimization. Nurse navigators screened patients preoperatively, identified and treated risk factors, and followed patients for 90 days postoperatively. We compared patients participating in our optimization program (N = 104) to both a historical cohort (N = 193) and a contemporary cohort (N = 166). RESULTS: Risk factor identification and optimization resulted in lower hospital length of stay (LOS) and postoperative emergency department (ED) visits. Patients in the optimization cohort had a statistically significant decrease in mean LOS as compared to both the historical cohort (2.55 vs 1.81 days, P < .001) and contemporary cohort (2.56 vs 1.81 days, P < .001). Patients in the optimization cohort had a statistically significant decrease in 30- and 90-day ED visits compared to the historical cohort (P30-day = .042, P90-day = .003). When compared with the contemporary cohort, the optimization cohort had a statistically significant decrease in 90-day ED visits (21.08% vs 10.58%, P = .025). The optimization cohort had a statistically significant increase in the percentage of patients discharged home. We noted nonsignificant reductions in readmission rate, transfusion rate, and surgical site infections. CONCLUSION: Optimization of patients before elective primary total hip arthroplasty and total knee arthroplasty reduced average LOS, ED visits, and drove telerehabilitation use. Our results add to the limited body of literature supporting this patient-centered approach.

BRCA Challenge: BRCA Exchange as a global resource for variants in BRCA1 and BRCA2.

The BRCA Challenge is a long-term data-sharing project initiated within the Global Alliance for Genomics and Health (GA4GH) to aggregate BRCA1 and BRCA2 data to support highly collaborative research activities. Its goal is to generate an informed and current understanding of the impact of genetic variation on cancer risk across the iconic cancer predisposition genes, BRCA1 and BRCA2. Initially, reported variants in BRCA1 and BRCA2 available from public databases were integrated into a single, newly created site, www.brcaexchange.org. The purpose of the BRCA Exchange is to provide the community with a reliable and easily accessible record of variants interpreted for a high-penetrance phenotype. More than 20,000 variants have been aggregated, three times the number found in the next-largest public database at the project's outset, of which approximately 7,250 have expert classifications. The data set is based on shared information from existing clinical databases-Breast Cancer Information Core (BIC), ClinVar, and the Leiden Open Variation Database (LOVD)-as well as population databases, all linked to a single point of access. The BRCA Challenge has brought together the existing international Evidence-based Network for the Interpretation of Germline Mutant Alleles (ENIGMA) consortium expert panel, along with expert clinicians, diagnosticians, researchers, and database providers, all with a common goal of advancing our understanding of BRCA1 and BRCA2 variation. Ongoing work includes direct contact with national centers with access to BRCA1 and BRCA2 diagnostic data to encourage data sharing, development of methods suitable for extraction of genetic variation at the level of individual laboratory reports, and engagement with participant communities to enable a more comprehensive understanding of the clinical significance of genetic variation in BRCA1 and BRCA2.

Barcoded nanoparticles for high throughput in vivo discovery of targeted therapeutics.

Nucleic acid therapeutics are limited by inefficient delivery to target tissues and cells and by an incomplete understanding of how nanoparticle structure affects biodistribution to off-target organs. Although thousands of nanoparticle formulations have been designed to deliver nucleic acids, most nanoparticles have been tested in cell culture contexts that do not recapitulate systemic in vivo delivery. To increase the number of nanoparticles that could be tested in vivo, we developed a method to simultaneously measure the biodistribution of many chemically distinct nanoparticles. We formulated nanoparticles to carry specific nucleic acid barcodes, administered the pool of particles, and quantified particle biodistribution by deep sequencing the barcodes. This method distinguished previously characterized lung- and liver- targeting nanoparticles and accurately reported relative quantities of nucleic acid delivered to tissues. Barcode sequences did not affect delivery, and no evidence of particle mixing was observed for tested particles. By measuring the biodistribution of 30 nanoparticles to eight tissues simultaneously, we identified chemical properties promoting delivery to some tissues relative to others. Finally, particles that distributed to the liver also silenced gene expression in hepatocytes when formulated with siRNA. This system can facilitate discovery of nanoparticles targeting specific tissues and cells and accelerate the study of relationships between chemical structure and delivery in vivo.