Improving obstetric and perinatal outcomes with a remote patient monitoring program for hypertension in a large integrated care system.

OBJECTIVE: To determine the effect of a remote patient monitoring program for hypertension (RPM HTN) in patients diagnosed with hypertensive disorders of pregnancy. STUDY DESIGN: We used a matched retrospective cohort design to evaluate differences in obstetric and perinatal outcomes using data from electronic medical records. Patients enrolled in RPM HTN between November 1, 2019, and October 31, 2021, who delivered a pregnancy at ≥20 weeks gestation were compared to a cohort of patients matched by age, race, HTN and diabetes status, who delivered in the 48-month period before implementation of RPM HTN. RESULTS: 1030 patients were enrolled in RPM HTN and 937 were matched to historical controls. Five hundred and seventeen (50.2 %) were enrolled in the antepartum period and 513 (49.8 %) were enrolled postpartum. Patients in the RPM HTN cohort were more likely to have a post-hospital discharge blood pressure (BP) measured within the first 20 days after delivery (RR 1.56, 95 % CI: 1.47-1.65: p < 0.01) and were more likely to have that BP be normal (RR 1.43, 95 % CI: 1.31-1.55: p = 0.05). They were also more likely to be taking antihypertensives postpartum (RR 1.27, 95 % CI: 1.15-1.40; p < 0.01) and to be evaluated by an obstetric clinician within 20 days of delivery (RR 1.50, 95 % CI 1.42-1.58; p < 0.01). CONCLUSIONS: A remote HTN monitoring program for 937 obstetric patients was associated with improved BP monitoring, better postpartum BP control, and improved linkages to clinician care after delivery, when compared to historical controls.

Clinical characteristics and social determinants of health associated with 30-day hospital readmissions of patients with COVID-19.

COVID-19 readmissions are associated with increased patient mortality and healthcare system strain. This retrospective cohort study of PCR-confirmed COVID-19 positive adults (>18 years) hospitalized and readmitted within 30 days of discharge from index admission was performed at eight Atlanta hospitals from March to December 2020. The objective was to describe COVID-19 patient-level demographics and clinical characteristics, and community-level social determinants of health (SDoH) that contribute to 30-day readmissions. Demographics, comorbidities, COVID-19 treatment, and discharge disposition data were extracted from the index admission. ZIP codes were linked to a demographic/lifestyle database interpolating to community-level SDoH. Of 7155 patients with COVID-19, 463 (6.5%) had 30-day, unplanned, all-cause hospital readmissions. Statistically significant differences were not found in readmissions stratified by age, sex, race, or ethnicity. Patients with a high-risk Charlson Comorbidity Index had higher odds of readmission (OR 4.8 (95% CI: 2.1 to 11.0)). Remdesivir treatment and intensive care unit (ICU) care were associated with lower odds of readmission (OR 0.5 (95% CI: 0.4 to 0.8) and OR 0.5 (95% CI: 0.4 to 0.7), respectively). Patients residing in communities with larger average household size were less likely to be readmitted (OR 0.7 (95% CI: 0.5 to 0.9). In this cohort, patients who received remdesivir, were cared for in an ICU, and resided in ZIP codes with higher proportions of residents with increased social support had lower odds of readmission. These patient-level factors and community-level SDoH may be used to identify patients with COVID-19 who are at increased risk of readmission.

Clinical, behavioural and social factors associated with racial disparities in COVID-19 patients from an integrated healthcare system in Georgia: a retrospective cohort study.

OBJECTIVES: To identify sociodemographic, clinical and behavioural drivers of racial disparities and their association with clinical outcomes among Kaiser Permanente Georgia (KPGA) members with COVID-19. DESIGN: Retrospective cohort of patients with COVID-19 seen from 3 March to 29 October 2020. We described the distribution of underlying comorbidities, quality of care metrics, demographic and social determinants of health (SDOH) indicators across race groups. We also described clinical outcomes in hospitalised patients including length of stay, intensive care unit (ICU) admission, readmission and mortality. We performed multivariable analyses for hospitalisation risk among all patients with COVID-19 and stratifyied by race and sex. SETTING: KPGA, an integrated healthcare system. PARTICIPANTS: 5712 patients who all had laboratory-confirmed COVID-19. Of them, 57.8% were female, 58.4% black, 29.5% white, 8.5% Hispanic and 3.6% Asian. RESULTS: Black patients had the highest proportions of living in neighborhoods under the federal poverty line (12.4%) and in more deprived locations (neighbourhood deprivation index=0.4). Overall, 14.4% (n=827) of this cohort was hospitalised. Asian patients had the highest rates of ICU admission (53.1%) and mechanical ventilation (21.9%). Among all patients, Hispanics (adjusted 1.60, 95% CI (1.08, 2.37)), blacks (1.43 (1.13, 1.83)), age in years (1.03 (1.02, 1.04)) and living in a zip code with high unemployment (1.08 (1.03, 1.13)) were associated with higher odds of hospitalisation. COVID-19 patients with chronic obstructive pulmonary disease (2.59 (1.67, 4.02)), chronic heart failure (1.79 (1.31, 2.45)), immunocompromised (1.77 (1.16, 2.70)), with glycated haemoglobin >8% (1.68 (1.19, 2.38)), depression (1.60 (1.24, 2.06)), hypertension (1.5 (1.21, 1.87)) and physical inactivity (1.25 (1.03, 1.51)) had higher odds of hospitalisation. CONCLUSIONS: Black and Hispanic KPGA patients were at higher odds of hospitalisation, but not mortality, compared with other race groups. Beyond previously reported sociodemographics and comorbidities, factors such as quality of care, lifestyle behaviours and SDOH indicators should be considered when designing and implementing interventions to reduce COVID-19 racial disparities.

Health Care Utilization and Clinical Characteristics of Nonhospitalized Adults in an Integrated Health Care System 28-180 Days After COVID-19 Diagnosis - Georgia, May 2020-March 2021.

As of April 19, 2021, 21.6 million COVID-19 cases had been reported among U.S. adults, most of whom had mild or moderate disease that did not require hospitalization (1). Health care needs in the months after COVID-19 diagnosis among nonhospitalized adults have not been well studied. To better understand longer-term health care utilization and clinical characteristics of nonhospitalized adults after COVID-19 diagnosis, CDC and Kaiser Permanente Georgia (KPGA) analyzed electronic health record (EHR) data from health care visits in the 28-180 days after a diagnosis of COVID-19 at an integrated health care system. Among 3,171 nonhospitalized adults who had COVID-19, 69% had one or more outpatient visits during the follow-up period of 28-180-days. Compared with patients without an outpatient visit, a higher percentage of those who did have an outpatient visit were aged ≥50 years, were women, were non-Hispanic Black, and had underlying health conditions. Among adults with outpatient visits, 68% had a visit for a new primary diagnosis, and 38% had a new specialist visit. Active COVID-19 diagnoses* (10%) and symptoms potentially related to COVID-19 (3%-7%) were among the top 20 new visit diagnoses; rates of visits for these diagnoses declined from 2-24 visits per 10,000 person-days 28-59 days after COVID-19 diagnosis to 1-4 visits per 10,000 person-days 120-180 days after diagnosis. The presence of diagnoses of COVID-19 and related symptoms in the 28-180 days following acute illness suggests that some nonhospitalized adults, including those with asymptomatic or mild acute illness, likely have continued health care needs months after diagnosis. Clinicians and health systems should be aware of post-COVID conditions among patients who are not initially hospitalized for acute COVID-19 disease.

Periacetabular bone density after total hip arthroplasty a postmortem analysis.

To clinically verify the bony response to a press-fit acetabular component, this study assessed 5 postmortem-retrieved pelves with unilateral total hip arthroplasties. Changes in periacetabular bone density between implanted and contralateral bone were assessed with dual energy x-ray absorptiometry and computed tomography. At a mean of 9.1 years postarthroplasty, bone density decreased an average of 1.5% to 7.1% proximal and 12.8% medial to the cup. This supports shorter-term in vivo investigations demonstrating periacetabular stress shielding proximal to press-fit cups as well as computer models predicting bone loss medially, but in much greater magnitudes. Unlike femoral remodeling, the average magnitudes of pelvic bone loss are not extensive; therefore, we question whether periacetabular remodeling should be a primary concern for orthopedic surgeons.

The natural history of osteoarthritic bone cysts after uncemented total hip arthroplasty.

This study quantified the radiographic changes of osteoarthritic acetabular bone cysts after uncemented total hip arthroplasty (THA). Ten-year follow-up radiographs from 130 primary THAs were reviewed. Forty-one cysts were identified on immediate postoperative radiographs. Two-dimensional cyst size was measured postoperatively and on long-term radiographs. Mean initial cyst size was 1.0 +/- 0.9 cm(2). Four (10%) of the 41 cysts expanded over time. The average increase in cyst size was 5.1 +/- 8.6 cm(2) which equated to a mean size increase of 713%. Twenty-seven cysts (66%) shrank, and the remaining 10 cysts (24%) did not change with time. Because cysts located in zone II, near the dome hole of the cup, were statistically more likely to progress, we hypothesize that these cysts communicated with the joint space via these holes. We propose that placing the acetabular component to seal an osteoarthritic cyst from the joint space during THA can help prevent its subsequent progression and the risk of associated osteolysis.

Incidence and volume of pelvic osteolysis at early follow-up with highly cross-linked and noncross-linked polyethylene.

Highly cross-linked polyethylene has shown decreased wear rates as compared to conventional polyethylene. However, the impact of this decrease on the occurrence of osteolysis remains uncertain. Forty hips implanted with noncross-linked Enduron and 36 implanted with 5-Mrad cross-linked Marathon polyethylene had a computed tomography at a minimum of 5 years after arthroplasty. Polyethylene wear, osteolysis incidence, location, and volume were compared. The incidence of osteolysis was statistically greater for patients with noncross-linked Enduron (11/40, 28%) compared to patients with the moderately cross-linked Marathon (3/36, 8%; P = .04). The average lesion volume for hips with Enduron liners (7.5 +/- 6.7 cm(3)) was significantly greater than the average lesion volume for hips implanted with Marathon liners (1.2 +/- 0.1 cm(3), P = .01). Marathon cross-linked polyethylene has shown to have a decreased incidence and volume of pelvic osteolysis. Longer follow-up is necessary to determine if Marathon cross-linked polyethylene will continue to demonstrate the encouraging improved wear and osteolysis characteristics.

Characteristics of pelvic osteolysis on computed tomography after total hip arthroplasty.

UNLABELLED: We investigated the characteristics of pelvic osteolysis using computed tomography to assess osteolytic patterns associated with five acetabular cup designs. Additionally, we examined the relationship between polyethylene wear and volume of pelvic osteolysis. We measured defect volume on the computed tomography images of 126 hips at a mean of 10.9 years after arthroplasty. Defects were classified as osteolysis if there was: (1) a well-defined sclerotic border, (2) no radiographic evidence that the defect existed before hip arthroplasty, and (3) a clear communication between the defect and the joint space. We identified 225 bone defects in 116 hips. Of these, 184 defects in 101 hips fulfilled our criteria for osteolysis. We found that lesion size and the location of the communication pathways depended on the cup design. Osteolysis occurred primarily through central holes, and occurred only around the rim if there were no holes in the cup. The lesions that communicated only through central holes and those with multiple communications tended to be larger than rim-related lesions. There was a moderate correlation between volumetric polyethylene wear and osteolysis volume. Communication pathways between lesions and the joint space are valuable for diagnosing osteolysis on computed tomography. Lesion volume, location, and type of communication pathway to the joint are influenced by cup design. LEVEL OF EVIDENCE: Therapeutic study, Level IV-1 (retrospective case series). See the Guidelines for Authors for a complete description of levels of evidence.

Comparison of CT, MRI, and radiographs in assessing pelvic osteolysis: a cadaveric study.

In this study, we compared the accuracy of radiography, computed tomography, and magnetic resonance imaging in assessing periacetabular osteolytic lesions. Using a previously published cadaver model, we created 87 lesions in pelves implanted with total hip replacement components. The sensitivity for detecting lesions was 51.7% for radiography, 74.7% for computed tomography, and 95.4% for magnetic resonance imaging. For all three techniques, sensitivity increased as lesion size increased. Magnetic resonance imaging emerged as the most effective tool for detecting small periacetabular osteolytic lesions (< or = 3 cm). For lesions larger than 3 cm, which are of more concern clinically, computed tomography and magnetic resonance imaging were effective in identifying lesions with detection rates greater than 80%. For radiography and computed tomography, lesion detection was dependent on lesion location, whereas magnetic resonance imaging had consistently good sensitivity in all lesion locations. Although the mean volumetric errors for computed tomography and magnetic resonance imaging (0.3 cm and 0.8 cm) were small compared with mean lesion volume (6.1 cm), computed tomography was more accurate than magnetic resonance imaging at measuring lesion volume, with a lower mean absolute error. This study verifies the problems associated with radiographic detection of osteolysis while showing the effectiveness of computed tomography and magnetic resonance imaging in determining the presence of lesions and assessing their three-dimensional volume.

Diagnostic features of pelvic osteolysis on computed tomography: the importance of communication pathways.

BACKGROUND: Progressive periacetabular osteolysis following total hip arthroplasty may require revision surgery. The purpose of this study was to use computed tomography scans of hemipelves retrieved at autopsy from patients who had had a total hip arthroplasty, to define the radiographic characteristics that differentiate clinically important osteolytic lesions from osteoarthritic bone cysts. METHODS: We analyzed forty-four hemipelves that had been retrieved at autopsy at a mean of eight years after a total hip arthroplasty with an uncemented acetabular component. Computed tomography images were analyzed to identify the location, volume, and presence of cortical erosion and/or communication pathways with the joint space for all periacetabular bone defects. Lesions that were not present on preoperative or immediate postoperative plain radiographs were defined as new lesions. These new lesions were compared with those that were present on preoperative or immediate postoperative plain radiographs, which were defined as preexisting lesions. RESULTS: Forty-six lesions were identified on computed tomography, and sixteen of them were preexisting lesions. The mean volume of the preexisting lesions was 1.5 +/- 1.5 cm(3), which was significantly smaller than the mean volume of 5.6 +/- 11.4 cm(3) of the thirty new lesions (p = 0.034). Twenty-eight of the thirty new lesions had a clear communication pathway with the joint space, while thirteen of the sixteen preexisting lesions demonstrated no communication pathway. New lesions were significantly more likely to communicate with the joint space than were preexisting lesions (p < 0.001). Cortical erosion was seen in sixteen of the thirty new lesions; none of the sixteen preexisting lesions exhibited cortical erosion (p < 0.001). CONCLUSIONS: The most important difference between osteolytic lesions and preexisting bone defects was the presence of a communication pathway to the joint space. Lesions that did not have an identifiable communication to the joint space were smaller and were not associated with cortical erosion. Lesions with communication to the joint through multiple pathways or through a central dome hole were larger and more likely to be associated with cortical erosion.

Magnetic resonance imaging in the evaluation of periprosthetic acetabular osteolysis: a cadaveric study.

Periprosthetic osteolysis is a well recognized complication of total hip arthroplasty that leads to implant failure. The ability to accurately assess and visualize the position and volume of periacetabular bone defects is paramount for clinical observation and medical treatment, as well as pre-operative planning of revision surgery. We have developed a modified magnetic resonance imaging (MRI) protocol that is useful in detection and quantification of periacetabular bone loss. The purpose of this study is to compare MRI to plain film analysis in the assessment of periacetabular bone loss using a cadaver model. MRI was 95% sensitive in the detection of lesions. Specificity was 98%, and accuracy was 96%. Lesion detection was not statistically dependent on lesion location (p=0.27). The mean absolute error in determining lesion size was 0.8+/-2.2 cm3. There was a correlation between increasing lesion size and lesion detection (p=0.02, logistic regression). The largest lesion that was missed by MRI analysis measured 2.8 cm3, and all lesions 3.0 cm3 were correctly identified, with a relative error volume measurement of 12.4+/-25.3%. This correlated to an absolute error of 1.4+/-2.4 cm3. Using conventional radiographic analysis, the overall sensitivity of lesion detection was 52%, and the specificity was 96%. Using plain film analysis, identification of true lesions depended on the location with 83% of ilial lesions, 64% of pubic lesions, 55% of ischial lesions, and 0% of posterior wall lesions correctly identified. The modified MRI technique utilized did allow for accurate visualization of simulated osteolytic lesions, and may provide a suitable noninvasive method to provide serial assessment of clinical periacetabular osteolysis without the use of ionizing radiation.

Computed tomography in the assessment of periacetabular osteolysis.

BACKGROUND: Computed tomography recently has been proposed as an accurate method for diagnosing periacetabular osteolytic lesions. Several investigators have attempted to validate the accuracy of this technique, but they employed cadaveric and animal models, which cannot replicate the adaptive changes that occur over time in vivo. This study was performed to determine the accuracy of computed tomography in identifying and measuring periacetabular osteolytic lesions in hemipelves retrieved at autopsies of individuals with a previously well-functioning total hip prosthesis. METHODS: We evaluated nine hemipelves, retrieved at autopsy, that contained a cementless porous-coated acetabular component. The fresh specimens were examined with conventional radiographs and computed tomography and then were embedded and sectioned into 1.5-mm slices for evaluation with slab radiographs. Anteroposterior and iliac oblique plain radiographs as well as axial, coronal, and sagittal computed tomography scans were reviewed to determine the presence and location of any periacetabular osteolytic lesions. These results were then compared with those identified on the slab radiographs. Lesion volume was calculated from computed tomography scans with use of post-processing software. RESULTS: A total of twenty-three periacetabular osteolytic lesions were identified on the slab radiographs of the nine hemipelves. The plain radiographs identified twelve (52%) of the twenty-three lesions, and the computed tomography scans identified twenty (87%) of the twenty-three lesions. Three medial wall perforations were identified on the computed tomography scans but were not detected on the plain radiographs. Computed tomography was accurate in measuring the volume of the osteolytic lesions (r(2) = 0.997) but tended to overestimate the volumes measured on the slab radiographs. Periacetabular osteolytic lesions appeared on the computed tomography scans and slab radiographs as areas devoid of trabecular bone that were delineated by a sclerotic border and communicated with the joint space. CONCLUSIONS: In this autopsy model, computed tomography was an accurate method for detecting the location and measuring the volume of periacetabular osteolytic lesions.

Sensitivity and specificity of plain radiographs for detection of medial-wall perforation secondary to osteolysis.

Medial-wall perforation secondary to pelvic osteolysis impacts planning of acetabular revision surgery and may result in pelvic fracture. We compared commonly used radiographic signs for detecting medial-wall perforation (ballooning or discontinuity of Kohler's line or the iliopubic line) to findings from computed tomography (CT) in 27 cementless total hip arthroplasty patients with pelvic osteolysis. Used alone, none of the radiographic signs examined were reliable for detecting medial-wall perforation. When assessed together, however, the development of a discontinuity of Kohler's line, the iliopubic line, or both on anteroposterior pelvic radiographs was a reliable indicator for the presence of medial-wall perforation. Thus, the authors recommend a CT scan to evaluate the integrity of the medial wall when a discontinuity of Kohler's line or the iliopubic line has occurred and a revision surgery is planned.

Management of patients with acetabular socket wear and pelvic osteolysis.

Polyethylene wear and pelvic osteolysis are the most common late complications associated with stable cementless total hip implants. This manuscript describes the diagnostic strategies and treatment algorithm used at the senior author's (C.A.E) institution for patients with wear and pelvic osteolysis. This evolving management strategy is based on our experiences and ongoing research. We discuss patient selection, the evaluation of acetabular liner wear, the diagnosis of pelvic osteolysis, the timing of revision, and treatment strategies. According to this algorithm, we revise asymptomatic hips with pending or complete wear-through of the acetabular liner. We also recommend revision for most symptomatic patients with pelvic osteolysis and for patients with large pelvic osteolytic bone defects or a documented increase in osteolytic lesion size in an area of the cementless acetabular component in which a load transfer between the implant and the surrounding bone is likely to occur.