Local infiltration for postsurgical analgesia following total hip arthroplasty: a comparison of liposomal bupivacaine to traditional bupivacaine.

OBJECTIVE: To assess postsurgical clinical and economic outcomes of patients who received local infiltration containing liposomal bupivacaine versus traditional bupivacaine for pain management following total hip arthroplasty (THA). METHODS: This retrospective study included two groups of consecutive patients undergoing THA. The experimental group received local infiltration with a combination of liposomal bupivacaine, bupivacaine HCl 0.25% with epinephrine 1:200,000, and ketorolac for postsurgical analgesia. The historical control group received the previous standard of care: local infiltration with a combination of bupivacaine HCl 0.25% with epinephrine 1:200,000 and ketorolac. Key outcomes included distance walked, length of stay (LOS), opioid medication use, numeric pain scores, hospital charges, hospital costs, all-cause 30 day readmission rate, and adverse events (AEs). Both unadjusted and adjusted (i.e. age, sex, insurance type, living situation, body mass index, procedure side, and comorbidity) outcomes were compared between the two groups. RESULTS: The experimental group (n = 64) demonstrated statistically significant improvement versus the historical control group (n = 66) in mean distance walked on discharge day (249.2 vs. 180.0 feet; unadjusted p = .025, adjusted p = .070), mean LOS (2.0 vs. 2.7 days; p < .001, p = .002), proportion of patients who used opioid rescue medication on postoperative day (POD) 1 (29.7% vs. 56.1%; p = .002, p = .003) and POD 2 (7.8% vs. 30.3%; p = .001, p = .003), mean cumulative area under the curve for pain score on POD 0 (127.6 vs. 292.5; p < .001, both), POD 1 (92.9 vs. 185.0; p < .001, both), and POD 2 (93.8 vs. 213.8; p = .006, both). Among a subgroup of patients with available financial information, mean hospital charges were lower in the experimental group ($43,794 [n = 24] vs. $48,010 [n = 66]; p < .001, both). Rates of all-cause 30 day readmission and AEs were not significantly different between groups. No falls occurred. CONCLUSIONS: Infiltration at the surgical site with liposomal bupivacaine was associated with improved postsurgical outcomes when compared with traditional bupivacaine in patients undergoing THA.

Long-term risk of colorectal cancer by gender after positive colonoscopy: population-based cohort study.

BACKGROUND: Evidence for surveillance intervals of colonoscopy are primarily based on adenoma recurrence rate rather than on colorectal cancer (C.R.C.) incidence. Little is known about long-term risk of C.R.C. after positive colonoscopy. In view of men have significantly higher C.R.C. risk than women, we aimed to estimate the gender-specific C.R.C. incidence after positive colonoscopy (adenoma or malignant lesion) at follow-up colonoscopy. METHODS: A retrospective cohort study was conducted using data from a database of colonoscopy screening and surveillance. Patients having had a colonoscopy (January 2010-March 2014) were selected as study subjects and the history of prior colonoscopies was reviewed. Multivariable Weibull regression models were used to estimate the incidence of C.R.C. at follow-up colonoscopy for subjects who were assigned a stratified risk level. The benchmark risk was defined according to a national survey. RESULTS: The interval incidence of C.R.C. at a 10 year follow-up was 164 (95% C.I. 63-343) and 79 (95% C.I. 26-188) per 100,000 person-years for low-risk men and women respectively, which tallied with our benchmark risk. Men exceeded the benchmark risk in 3-5 years if they had an incomplete polyp removal, ≥3 adenomas during their last colonoscopy or a personal C.R.C. history, and in 7-8 years if they only had familial C.R.C. HISTORY: Women had a lower risk of C.R.C., and reached a same risk level 3-5 years later than men. Coexisting above risk factors resulted in a sharp increase in the incidence of C.R.C. at follow-up exceeding the benchmark much earlier. CONCLUSION: Surveillance intervals for men based on incidence of C.R.C. are in line with that recommended by the current guidelines for colonoscopy. However, an extension of 3-5 years may be appropriate for women. To target personalized medicine, a risk predictive model could be used to identify an appropriate surveillance interval for each individual in the future.

Cost-benefit evaluation of liposomal bupivacaine in the management of patients undergoing total knee arthroplasty.

PURPOSE: Results of a cost-benefit analysis of intraoperative use of liposomal bupivacaine for postsurgical pain management in patients undergoing total knee arthroplasty (TKA) are presented. METHODS: In a retrospective single-site study, clinical and cost outcomes were compared in a group of 134 consecutive patients who received liposomal bupivacaine (by local infiltration) during TKA and a propensity score-matched historical cohort of 134 patients undergoing TKA who received usual care (continuous femoral nerve blockade with conventional bupivacaine delivered via elastomeric pump). RESULTS: Postsurgical pain scores and opioid use were similar in the two study groups; the mean total amount of nonsteroidal antiinflammatory drugs administered was lower in the liposomal bupivacaine group. Patients who received liposomal bupivacaine typically ambulated earlier than those who received usual care (22% and 3%, respectively, walked on the day of surgery; p < 0.05) and were more likely to be discharged within two days (50% versus 19%, p < 0.001); on average, liposomal bupivacaine- treated patients walked farther on the day of surgery (6.0 m versus 3.1 m, p < 0.001) and the day after surgery (63.7 m versus 25.5 m, p < 0.001) and had a shorter length of stay (LOS) (3.1 days versus 3.6 days, p < 0.03). The mean adjusted total direct hospital cost per patient was significantly lower with liposomal bupivacaine use versus usual care ($8758 versus $9213, p = 0.033). CONCLUSION: In patients undergoing TKA, intraoperative administration of liposomal bupivacaine for management of postsurgical pain was found to offer advantages over usual care, including decreased time to ambulation and reduced hospital LOS.

Explaining the link between access-to-care factors and health care resource utilization among individuals with COPD.

BACKGROUND: Limited accessibility to health care may be a barrier to obtaining good care. Few studies have investigated the association between access-to-care factors and COPD hospitalizations. The objective of this study is to estimate the association between access-to-care factors and health care utilization including hospital/emergency department (ED) visits and primary care physician (PCP) office visits among adults with COPD utilizing a nationally representative survey data. METHODS: We conducted a pooled cross-sectional analysis based upon a bivariate probit model, utilizing datasets from the 2011-2012 Behavioral Risk Factor Surveillance System linked with the 2014 Area Health Resource Files among adults with COPD. Dichotomous outcomes were hospital/ED visits and PCP office visits. Key covariates were county-level access-to-care factors, including the population-weighted numbers of pulmonary care specialists, PCPs, hospitals, rural health centers, and federally qualified health centers. RESULTS: Among a total of 9,332 observations, proportions of hospital/ED visits and PCP office visits were 16.2% and 44.2%, respectively. Results demonstrated that access-to-care factors were closely associated with hospital/ED visits. An additional pulmonary care specialist per 100,000 persons serves to reduce the likelihood of a hospital/ED visit by 0.4 percentage points (pp) (P=0.028). In contrast, an additional hospital per 100,000 persons increases the likelihood of hospital/ED visit by 0.8 pp (P=0.008). However, safety net facilities were not related to hospital utilizations. PCP office visits were not related to access-to-care factors. CONCLUSION: Pulmonary care specialist availability was a key factor in reducing hospital utilization among adults with COPD. The findings of our study implied that an increase in the availability of pulmonary care specialists may reduce hospital utilizations in counties with little or no access to pulmonary care specialists and that since availability of hospitals increases hospital utilization, directing patients with COPD to pulmonary care specialists may decrease hospital utilizations.

Race Differences: Use of Walking Speed to Identify Community-Dwelling Women at Risk for Poor Health Outcomes--Osteoarthritis Initiative Study.

BACKGROUND: Onset of disability, risk for future falls, frailty, functional decline, and mortality are strongly associated with a walking speed of less than 1.0 m/s. OBJECTIVE: The study objective was to determine whether there were differences in slow walking speed (<1.0 m/s) between community-dwelling African American and white American adult women with osteoarthritis symptoms. An additional aim was to examine whether racial differences in walking speed can be attributed to age, obesity, socioeconomic factors, disease severity, or comorbidities. DESIGN: A cross-sectional design was used. METHODS: Community-dwelling adults were recruited from Baltimore, Maryland; Columbus, Ohio; Pittsburgh, Pennsylvania; and Pawtucket, Rhode Island. Participants were 2,648 women (23% African American) who were 45 to 79 years of age and had a self-selected baseline walking speed of 20 m/s in the Osteoarthritis Initiative Study. Mixed-effects logistic regression models were used to examine racial differences in walking speed (<1.0 m/s versus ≥1.0 m/s), with adjustments for demographic factors, socioeconomic factors, disease severity, and comorbidities. RESULTS: Walking speed was significantly slower for African American women than for white American women (mean walking speed=1.19 and 1.33 m/s, respectively). The prevalence of a walking speed of less than 1.0 m/s in this cohort of middle-aged women was 9%; about 50% of the women with a walking speed of less than 1.0 m/s were younger than 65 years. Women with a walking speed of less than 1.0 m/s had lower values for socioeconomic factors, higher values for disease severity, and higher prevalences of obesity and comorbidities than those with a walking speed of ≥1.0 m/s. After controlling for these covariates, it was found that African American women were 3 times (odds ratio=2.9; 95% confidence interval=2.0, 4.1) more likely to have a walking speed of less than 1.0 m/s than white American women. LIMITATIONS: The study design made it impossible to know whether a walking speed of less than 1.0 m/s in women who were 45 years of age or older was a predictor of future poor health outcomes. CONCLUSIONS: In this study, race was independently associated with a walking speed of less than 1.0 m/s in community-dwelling women who had or were at risk for osteoarthritis, with African American women having 3 times the risk for slow walking as white American women. This finding suggests that middle-aged African American women have an increased risk for poor health outcomes. Further longitudinal evaluations are needed to confirm the long-term health outcomes in a middle-aged population and to establish walking speed as a useful tool for identifying middle-aged women at high risk for poor health outcomes.

Risk of using logistic regression to illustrate exposure-response relationship of infectious diseases.

BACKGROUND: In most biological experiments, especially infectious disease, the exposure-response relationship is interrelated by a multitude of factors rather than many independent factors. Little is known about the suitability of ordinary, categorical exposures, and logarithmic transformation which have been presented in logistic regression models to assess the likelihood of an infectious disease as a function of a risk or exposure. This study aims to examine and compare the current approaches. METHODS: A simulated human immunodeficiency virus (HIV) population, dynamic infection data for 100,000 individuals with 1% initial prevalence and 2% infectivity, was created. Using the Monte Carlo method (computational algorithm) to repeat random sampling to obtain numerical results, linearity between log odds and exposure, and suitability in practice were examined in the three model approaches. RESULTS: Despite diverse population prevalence, the linearity was not satisfied between log odds and raw exposures. Logarithmic transformation of exposures improved the linearity to a certain extent, and categorical exposures satisfied the linear assumption (which was important for modelling). When the population prevalence was low (assumed < 10%), performances of the three models were significantly different. Comparing to ordinary logistic regression, the logarithmic transformation approach demonstrated better accuracy of estimation except that at the two inflection points: likelihood of infection increased from slowly to sharply, then slowly again. The approach using categorical exposures had better estimations around the real values, but the measurement was coarse due to categorization. CONCLUSIONS: It is not suitable to directly use ordinary logistic regression to explore the exposure-response relationship of HIV as an infectious disease. This study provides some recommendations for practical implementations including: 1) utilize categorical exposure if a large sample size and low population prevalence are provided; 2) utilize a logarithmic transformed exposure if the sample size is insufficient or the population prevalence is too high (such as 30%).

Characterization of patients undergoing total hip arthroplasty in a real-world setting and pain-related medication prescriptions for management of postoperative pain.

This observational study characterized medication use in the immediate postoperative period among patients undergoing total hip arthroplasty (THA) at an academic medical center, and evaluated pain (0-10 numerical pain rating scale [NPRS]; 0 = no pain, 10 = worst pain that the patient can imagine), function (Harris Hip Score [HSS]and Lower Extremity Function Scale [LEFS]), and health-related quality of life (SF-36). Study patients (N = 115; 59% female; average age 61.3 ± 12.0 years; mean BMI of 29.9 ± 6.9 kg/m2) who underwent THA between September 1, 2008, and November 30, 2010, and met study inclusion criteria were drawn from the University of Utah Orthopedic Clinic database. The most common comorbidities in these patients were osteoarthritis, hypertension, and chronic back pain. The most frequently prescribed class of pain-related medications in the immediate postoperative period was opioids. The most common nonopioid medications were bupivacaine, celecoxib, and midazolam. Opioids and celecoxib continued to be commonly prescribed at discharge. Pain was improved at a 6-week follow-up (mean change −3.3 ± 3.3 points), as were HSS and LEFS, with mean changes of 19.9 ± 24.2 and 8.7 ± 16.9 points (P < .01 for both), respectively. Although SF-36 scores were also improved, these scores were significantly lower relative to normative values for the US general population as well as relative to individuals having both osteoarthritis and hypertension.

Trends and predictors in methadone maintenance treatment dropout in Shanghai, China: 2005-2011.

BACKGROUND: The methadone maintenance treatment (MMT) program has been implemented in Shanghai since 2005. This study aims to portray the trend of MMT dropout and identify predictive factors that may influence dropout in Shanghai MMT clinics, which could assist in the intervention strategy development. METHODS: A retrospective evaluation was used in the Shanghai component of the National MMT data management system between January 1, 2005 and December 31, 2011. The Cox model for recurrence events was employed to estimate hazard ratio (HR) predicting dropout during the follow-up period. RESULTS: Of all 6169 participants, 63% dropped out of the program at least once (ranging from 0 to 10 times), and 74% of them did not return by the end of this study. The average monthly incidence rate of dropout was 4.4% with a range from 0 to 9.3%. Adjusted analyses demonstrated that the individuals with methadone tapering didn't have a greater probability of dropping out compared to those with stable dosage (HR = 1.07, 95% CI: 0.90-1.27). However, there was a higher dropout rate among younger individuals (<30 years vs. ≥50 years old; HR = 1.41, 95% CI: 1.16-1.71), among those who were less educated (HR = 1.48, 95% CI: 1.17-1.87), among those who shared needles with others (HR = 1.29, 95% CI: 1.06-1.58), among those whose urine tested positive for opiates (HR = 1.69, 95% CI: 1.51-1.89), and among those who had a low average methadone dose at the initial stable stage of treatment (≤35 mg/day vs. >65 mg/day; HR = 1.39, 95% CI: 1.19-1.63). CONCLUSIONS: Shanghai has been facing the challenge of keeping a high MMT retention rate. Increasing the use of methadone tapering after a stable treatment stage with sufficient dosage could be attempted in the MMT program, as well as considering comprehensive interventions among specific populations, such as young, poorly educated, opiate-positive and needle sharing individuals.

Characterization of patients undergoing total knee arthroplasty in a real-world setting and pain-related medication prescriptions for management of postoperative pain.

Presently, no "gold-standard" exists for the management of pain after total knee arthroplasty (TKA) surgery. Understanding pain management methods used in clinical practice and the associated patient outcomes are necessary to fill gaps in pain management strategies. This study characterizes medication use in the immediate postoperative period among patients undergoing TKA at an academic medical center. Additionally, pre- and postoperative measures of pain (numeric pain rating scale), physical function (Knee Society Scale and Lower Extremity Function [LEFS]), and quality of life (Medical Outcomes Study Short-Form [SF]-36) were evaluated. The patient data were extracted from a clinical database at the University of Utah Orthopedic Clinic between September 1, 2008, and November 30, 2010. A total of 168 patients (mean age 64.0 ± 10.1 years, 63.1% were female, mean body mass index [BMI] 31.7 ± 7.1 kg/m(2)) were included. The most common comorbidities in these patients were osteoarthritis, hypertension, and major depressive disorders. Bupivacaine and fentanyl were commonly given on the day of surgery with oxycodone, hydrocodone/acetaminophen, and celecoxib prescribed at hospital discharge. Preoperative pain levels were reduced by half at 6 weeks. Physical function and quality of life were similar to established benchmarks and previously reported levels, respectively. Confirmation of results over a longer follow-up period is warranted.

Translating Research into Clinical Practice: Functional Recovery Post Total Hip Arthroplasty Using Outcomes Gathered in the Usual Physical Therapy Practice Setting.

PURPOSE: The purpose of this study is to determine the pattern of functional change after total hip arthroplasty (THA) in patients attending physical therapy (PT) in a usual care setting and to explore the effect of sex and time from surgery to the first physical therapy visit as potential prognostic factors influencing postoperative THA recovery. STUDY DESIGN: Adults with THA were retrospectively identified in an electronic medical record PT database (October 1, 2004-April 30, 2010). Hierarchical linear modeling was used to evaluate growth curves and individual variations in function using the Lower Extremity Function Scale (LEFS). Investigated predictors were: sex, age, start time, and PT visit. RESULTS: A total of 147 (81 female, 66 male) postoperative THA patients were included in the study; mean age was 62.7 years (SD 10.6, range 45-91 years). The majority (79%) of patients initiated PT <9 weeks postsurgery; predominately lower-functioning women started at ≥9 weeks. For patients initiating treatment at <9 weeks, the curvilinear slopes of recovery were similar between sexes, although the predicted levels of functional status were lower for females than for males (P = .041). CONCLUSIONS: This study of usual physical therapy practice supports the findings from controlled studies that post-THA women enter and are discharged from outpatient PT with lower functional status than men. New findings suggest that functional status for early start patients steadily improves over 26 weeks postsurgery. Modeling change in clinical practice using outcomes measures acquired through usual practice can feasibly and adequately serve to guide decisions in the management of THA rehabilitation.

Diabetes and associated risk factors in patients referred for physical therapy in a national primary care electronic medical record database.

OBJECTIVE: The prevalence of diabetes (type 2) in the general population has increased dramatically over the last decade, yet patients with diabetes are rarely referred for physical therapy management of their condition. The majority of patients referred for outpatient physical therapy have musculoskeletal-related conditions. Secondary conditions, such as diabetes, may be prevalent in this population, and physical therapists need to be aware of this to adjust interventions and treatment. The purpose of this article is to describe the prevalence of diabetes and the associated risk factors in adults referred for physical therapy in a primary care outpatient setting. SUBJECTS AND METHODS: Patients aged 18 years or older referred for physical therapy were identified from the Centricity Electronic Medical Records database during the period of December 13, 1995, to June 30, 2007. Patients were evaluated on the basis of clinical (height, weight, blood pressure, laboratory values), treatment (prescriptions), and diagnostic (ICD-9 codes) criteria to identify the presence of diabetes or associated risk factors (eg, hypertension, elevated triglycerides, low high-density lipoprotein, body mass index, and prediabetes). RESULTS: There were 52,667 patients referred for physical therapy, the majority of whom were referred for a musculoskeletal-related condition. Approximately 80% of the total study population had diabetes, prediabetes, or risk factors associated with diabetes. The prevalence of diabetes in the study population was 13.2%. Of the diabetes-associated risk factors evaluated, hypertension was the most prevalent (70.4%), and less than half (39.1%) of the study population had an elevated body mass index. Only 20% of the study population had values within normal limits for all clinical, treatment, and diagnostic criteria. Clinical and treatment measurements available to physical therapists identified the majority of associated risk factors. CONCLUSIONS: Although not the primary indications for referral, diabetes and associated risk factors were identified in a high proportion of the study population. The evaluation of associated conditions in the outpatient orthopedic setting needs to be considered for treatment planning adjustments and to optimize care.

The effect on comorbidity and pain in patients with osteoarthritis.

Comorbidities can affect how patients experience pain associated with chronic disease. Despite numerous studies on the association of pain with chronic conditions, few account for the multiple comorbidities associated with the highly prevalent chronic disease osteoarthritis (OA). OA generally is not lethal but it greatly impacts health care utilization and costs mainly primarily due to pain and disability. This paper describes how comorbidities impact OA pain reporting. We identified the common comorbidities associated with OA and examined the comorbidity measures utilized to identify the comorbidities. Using the identified comorbidities, we related how they may contribute to the pain experience for OA patients. We describe how OA treatment and multiple comorbidities may impact on treatment decisions.

The societal costs of low back pain: data published between 2001 and 2007.

The paper reviews low back pain (LBP) studies with economic implications in order to determine whether the societal cost attributed to lower back pain (LBP) have changed since 2001, a time during which LBP treatment guidelines were updated. A Medline search of publications 2001 and 2007 using broadly defined keywords produced 338 abstracts that were screened, of which 68 potentially relevant articles were retrieved and reviewed. Cost estimates for the management of LBP were high, consistent with the results of review of LBP economic studies published prior to 2001. Pharmacotherapy plays an important role in LBP treatment, although drug cost data in LBP is limited. Newer, more costly agents such cyclooxengenase-2 selective nonsterioidal anti-inflammatory agents will increase drug costs as a portion of total costs, particularly if not used in accordance with treatment guidelines.