The prevalence of rotator cuff pathology in the setting of acute proximal biceps tendon rupture.

BACKGROUND: The prevalence and severity of concomitant rotator cuff pathology in the setting of proximal biceps tendon ruptures are poorly understood. Concomitant rotator cuff disease may have important implications in the prognosis and natural history of this shoulder condition. Therefore, an observational cohort of patients with an acute rupture of the long head of the biceps tendon (LHBT) was evaluated to determine the prevalence and severity of concomitant rotator cuff disease. METHODS: Thirty consecutive patients diagnosed with acute proximal biceps tendon rupture were prospectively enrolled. Magnetic resonance imaging of the affected shoulder was obtained in 27 patients and reviewed by a fellowship-trained orthopedic surgeon. RESULTS: The cohort consisted of 20 men (74%) and 7 women (26%) (mean age, 61.0 years [range, 42-78 years]). The dominant side was involved in 20 injuries (74%), and a low-energy trauma mechanism of injury was involved in 23 (85%). Of the patients, 11 (41%) reported a history of antecedent shoulder pain. Magnetic resonance imaging assessment revealed that 93% of patients had evidence of rotator cuff disease, including 13 full-thickness tears. Of the full-thickness tears, 3 were small, 6 medium, 2 large, and 2 massive. Pathology of the subscapularis tendon was identified in 7 patients (26%). CONCLUSION: In this cohort, we found LHBT rupture to be highly correlated with the presence of rotator cuff disease, with the majority of patients presenting with full-thickness tears of the supraspinatus. These findings may have important implications in the treatment and prognosis of patients who present with acute LHBT ruptures.

Is there value in retrospective 90-day bundle payment models for shoulder arthroplasty procedures?

BACKGROUND: The Centers for Medicare & Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative was implemented as part of the Affordable Care Act. We implemented a retrospective payment model 2 for a 90-day total shoulder arthroplasty (TSA) episode to assess the value of TSA BPCI at our private practice. METHODS: Expenditures and postacute event rates of 132 fee-for-service (FFS) patients who underwent a TSA operation between 2009 and 2012 were compared with 333 BPCI patients who had a TSA operation in 2015. The 90-day postacute events included an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), and home health (HH) admissions and readmissions. Expenditures were converted to 2016 dollars using the Consumer Price Index. Wilcoxon tests and multivariate generalized estimating equation were used to assess independent cost-drivers. RESULTS: The median FFS expenditure was $21,157 (interquartile range, $16,894-$30,748) compared with $17,894 (interquartile range, $15,796-$20,894) for BPCI (P < .0001). The BPCI patients had significantly lower rates of SNF admissions (34% FFS vs. 16% BPCI; P < .001), IRF admissions (3% FFS vs. 0.6% BPCI; P = .05), HH utilization (49% FFS vs. 41% BPCI; P = .05), and readmissions (14% FFS vs. 7% BPCI; P = .01). After controlling for postacute events in the multivariate regression model, we found BPCI had a 4% decrease in expenditures (P = .08). All postacute events were independently associated with higher expenditures. CONCLUSIONS: Our private practice implemented cost-containment practices, including clinical guidelines, patient navigators, and a BPCI management team. IRF and SNF utilization and the 90-day readmission rate significantly decreased. As a result, we were able to control the postacute spending, which resulted in decreased costs of performing TSA surgery.

Perioperative Complication Rates in Pediatric Total Joint Arthroplasty Patients Compared With Adults: Results of a Matched Cohort Study.

BACKGROUND: One of the least studied areas in orthopaedics is total joint arthroplasty (TJA) in pediatric patients. Recent studies have confirmed that these procedures are being performed on pediatric patients, making it critical to understand the rates of surgical complications in this patient population. We sought to examine the frequency in which surgical complications occur in pediatric patients, aged 20 and younger, undergoing TJA compared with adults. METHODS: Data from the 2003 to 2012 Kids' Inpatient Database (ages 20 and younger) and 2002 to 2013 National Inpatient Sample (ages 21 and over) were analyzed. Pediatric patients were matched to 3 adult controls (1 per age group: 21 to 50, 51 to 65, and over 65 y) using patient characteristics including sex, race, orthopaedic diagnosis, and preoperative loss of function. Comparisons were then made between the rates and relative risks (RRs) of surgical complications between pediatric and adult patients. Finally, we examined patient factors associated with surgical complications, utilizing modified Poisson regression models with robust SEs. RESULTS: Three adult controls (ie, 1 control from each age group) were identified for 1385 pediatric patients, for a total sample of 5540 TJA patients. Approximately 10% of pediatric patients experienced either major or minor surgical complications. The overall rate of major complications in pediatric patients was 5.05%, compared with 4.79% in adult controls [RR: 1.06 (0.81 to 1.38), P=0.69]. The overall rate of minor complications in pediatric patients was 5.78%, compared with 5.68% in adult controls [RR: 1.02 (0.80 to 1.30), P=0.78]. When adjusted for patient demographics, the RR of major complications was 49% higher in pediatric patients compared with ages 21 to 50 [RR: 1.49 (1.03 to 2.16), P=0.03] with no statistically significant differences noted for other age groups. For minor complications, the adjusted RR in pediatric patients, compared with any other age group, did not approach statistical significance. CONCLUSIONS: Pediatric patients undergoing TJA experience major and minor surgical complications at rates comparable with their adult counterparts. Our findings offer important insight on the rates of surgical complications in pediatric TJA patients, which is valuable for preoperative education and consultation with patients and families. LEVEL OF EVIDENCE: Level III-therapeutic.

In-Hospital Complications Following Ankle Arthrodesis Versus Ankle Arthroplasty: A Matched Cohort Study.

BACKGROUND: Ankle arthrodesis has been the traditional surgical treatment for end-stage hindfoot arthritis. However, utilization of total ankle arthroplasty (TAA) is increasing as surgical techniques and implants have substantially improved. The purpose of this study was to compare the U.S. national rates of perioperative (in-hospital) complications between a statistically matched cohort of patients who underwent either an ankle arthrodesis or a TAA. METHODS: Data from the 2002 to 2013 Nationwide Inpatient Sample releases were analyzed. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes were used to identify 4,192 patients treated with TAA (ICD 81.56) and 16,278 treated with ankle arthrodesis (ICD 81.11). ICD-9-CM diagnosis codes were utilized to identify major and minor in-hospital complications, and mortality was determined using the Uniform Bill patient disposition. The arthrodesis and TAA groups were matched with regard to age, sex, race, surgery year, hospital type, comorbidities, adjunctive procedures, and surgical indication. Unadjusted and adjusted in-hospital complication risks were compared between groups using the Fisher exact test and multiple logistic regression analysis. RESULTS: We were able to statistically match 1,574 patients who underwent a TAA (37.5%) with a patient who underwent arthrodesis. A major in-hospital complication occurred in 8.5% (134) of the 1,574 patients in the ankle arthrodesis group compared with 5.3% (84) of the 1,574 in the TAA group (p < 0.001) whereas a minor complication was found in 4.7% (74) in the ankle arthrodesis group compared with 5.9% (93) in the TAA group (p = 0.14). There were no deaths in either group. After adjusting for case mix, we found that ankle arthrodesis was 1.8 times more likely to be followed by a major complication (odds ratio [OR] = 1.78, 95% confidence interval [CI] = 1.32 to 2.39) whereas the minor complication rate was 29% lower in that group (OR = 0.71, 95% CI = 0.45 to 1.13). CONCLUSIONS: In a matched cohort of 3,148 patients treated with either TAA or ankle arthrodesis, ankle arthrodesis was associated with a 1.8 times higher risk of a major complication but a 29% lower risk of a minor complication. Our findings are consistent with other studies that have shown TAA to be a safe procedure in the inpatient environment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

One-year Prevalence, Comorbidities, and Cost of Hospitalizations for Alpha-1 Antitrypsin Deficiency among Patients with Chronic Obstructive Pulmonary Disease in the United States.

Objectives: Little is known about severe chronic obstructive pulmonary disease (COPD) exacerbations among patients with Alpha-1 Antitrypsin Deficiency (AATD). We assessed inpatients with AATD and COPD among a sample of COPD inpatients to ascertain demographic, clinical and economic differences in the course of disease and treatment. Methods: Using data from the 2009 Nationwide Inpatient Sample (NIS), we identified COPD (ICD-9-CM: 491.xx, 492.xx, or 496.xx) patients with AATD (273.4). We compared patient demographics and healthcare outcomes (eg, length of stay, inpatient death, type and number of procedures, and cost of care) between COPD patients with and without alpha-1 antitrypsin deficiency. Frequencies and percentages for patient demographics were compared using bivariate statistics (eg, chi-square test). Recognizing the non-parametric nature of length of stay and cost, we calculated median values and interquartile ranges for these variables for each group of patients. Finally, the risk of inpatient death was estimated using logistic regression. Results: Of 840 242 patients with COPD (10.8% of the NIS sample population), 0.08% (684) had a primary or secondary diagnosis code for AATD. COPD+AATD were younger (56 vs 70, p<0.0001) and as a result, less likely to be covered by Medicare (44% vs 62%, p<0.0001). AATD patients were also more likely to have comorbid non-alcoholic liver disease (7% vs 2%, p<0.0001), depression (17% vs 13%, p=0.0328), and pulmonary circulation disorders (7% vs 4%, p=0.0299). Patients with AATD had a 14% longer length of stay (IRR = 1.14, 95% CI 1.07, 1.21) and a mean cost of $1487 (p=0.0251) more than COPD inpatients without AATD. Conclusions: AATD is associated with increased mean length of stay and cost, as well as higher frequency of comorbid non-alcoholic liver disease, depression, and pulmonary circulation disorders. Future research should assess other differences between AATD and the general COPD population such as natural history of disease, treatment responsiveness and disease progression.

Cachexia among US cancer patients.

BACKGROUND: Cancer cachexia is a debilitating condition and results in poor prognosis. The purpose of this study was to assess hospitalization incidence, patient characteristics, and medical cost and burden of cancer cachexia in the US. METHODS: This study used a cross-sectional analysis of the Nationwide Inpatient Sample (NIS) for 2009. Five cancers reported to have the highest cachexia incidence were assessed. The hospitalization incidence related to cachexia was estimated by cancer type, cost and length of stay were compared, and descriptive statistics were reported for each cancer type, as well as differences being compared between patients with and without cachexia. RESULTS: Risk of inpatient death was higher for patients with cachexia in lung cancer (OR = 1.32; CI = 1.20-1.46) and in all cancers combined (OR = 1.76; CI = 1.67-1.85). The presence of cachexia increased length of stay in lung (IRR = 1.05; CI = 1.03-1.08), Kaposi's sarcoma (IRR = 1.47; CI = 1.14-1.89) and all cancers combined (IRR = 1.09; CI = 1.08-1.10). Additionally, cachectic patients in the composite category had a longer hospitalization stay compared to non-cachectic patients (3-9 days for those with cachexia and 2-7 days for those without cachexia). The cost of inpatient stay was significantly higher in cachexic than non-cachexic lung cancer patients ($13,560 vs $13 190; p < 0.0001), as well as cachexic vs non-cachexic cancer patients in general (14 751 vs 13 928; p < 0.0001). CONCLUSIONS: Cachexia increases hospitalization costs and length of stay in several cancer types. Identifying the medical burden associated with cancer cachexia will assist in developing an international consensus for recognition and coding by the medical community and ultimately an effective treatment plans for cancer cachexia.

National Obesity Trends in Revision Total Knee Arthroplasty.

BACKGROUND: The utilization of primary total knee arthroplasty (TKA) in obese patients has increased significantly over the past decade despite overwhelming data that suggest higher failure rates. As such, it is reasonable to expect a parallel increase in obesity rates among revision TKA (rTKA) patients. The purpose of this study was to analyze longitudinal trends in obesity rates among rTKA patients. METHODS: We identified 451,982 rTKA patients using 2002-2012 Nationwide Inpatient Sample weighted discharge data. The Agency for Healthcare Research and Quality obesity comorbidity indicator was used to identify 70,470 obese patients (body mass index, >30) and 335,257 nonobese patients. We evaluated trends in obesity rates over time using chi-square tests and a multivariate logistic regression model, which included several covariates (patient age, gender, and race; payer type; hospital type; and patient health status). RESULTS: The obesity rate among rTKA patients increased significantly from 9.74% in 2002 to 24.57% in 2012 (P < .0001). After adjusting for all factors, patients treated in 2011 (odds ratio [OR]: 4.1, 95% CI: 3.7-4.6, P < .0001) or 2012 (OR: 4.5, 95% CI: 4.0-5.0, P < .0001) were over 4 times as likely to be obese, compared to patients treated in 2002. Other independent factors that were significantly associated with higher obesity rates include female patients (OR: 1.5, 95% CI: 1.5-1.6) and patients between the ages of 45 and 64 years (OR: 3.2, 95% CI: 3.1-3.3). CONCLUSION: The more than 4-fold increase in the obesity rate among patients undergoing rTKA, particularly the middle-age group, over the past decade is an alarming trend. Improved clinical care pathways are needed to manage the obese total knee patient.

A RCT comparing 7-year clinical outcomes of one level symptomatic cervical disc disease (SCDD) following ProDisc-C total disc arthroplasty (TDA) versus anterior cervical discectomy and fusion (ACDF).

PURPOSE: The objective of this trial was to compare the safety and efficacy of TDA using the ProDisc-C implant to ACDF in patients with single-level SCDD between C3 and C7. METHODS: We report on the single-site results from a larger multicenter trial of 13 sites using an approved US Food and Drug Administration protocol (prospective, randomized controlled non-inferiority design). Patients were randomized one-to-one to either the ProDisc-C device or ACDF. All enrollees were evaluated pre- and post-operatively at regular intervals through month 84. Visual Analog Scale (VAS) for neck and arm pain/intensity, Neck Disability Index (NDI), Short-Form 36 (SF-36), and satisfaction were assessed. RESULTS: Twenty-two patients were randomized to each arm of the study. Nineteen additional patients received the ProDisc-C via continued access. NDI improved with the ProDisc-C more than with ACDF. Total range of motion was maintained with the ProDisc-C, but diminished with ACDF. Neck and arm pain improved more in the ProDisc-C than ACDF group. Patient satisfaction remained higher in the ProDisc-C group at 7 years. SF-36 scores were higher in the TDA group than ACDF group at 7 years; the difference was not clinically significant. Six additional operations (two at the same level; four at an adjacent level) were performed in the ACDF, but none in the ProDisc-C group. CONCLUSIONS: The ProDisc-C implant appears to be safe and effective for the treatment of SCDD. Patients with the implant retained motion at the involved segment and had a lower reoperation rate than those with an ACDF.

Mental Health and Substance Misuse-Related Emergency Department Discharges in Urban Counties of North Carolina.

BACKGROUND: National evidence suggests that there is considerable variation between regions in emergency department utilization for routine health care needs. Many emergency departments are poorly equipped to manage the needs of patients with mental health or substance misuse diagnoses, who could often be more effectively managed in other settings. We sought to quantify differences in the frequency of mental health and substance misuse-related emergency department encounters across urban counties in North Carolina. METHODS: Data from the 2010 North Carolina State Emergency Department and Inpatient Databases were analyzed with descriptive, bivariate, and multivariate statistics. Primary discharge diagnoses were classified using the International Classification of Disease, Ninth Revision, Clinical Modification codes included with the databases. RESULTS: The overall rate of mental health and substance misuse encounters in urban counties was 19.1 encounters per 1,000 people (4.5% of all emergency department encounters). This rate ranged from 6.4 encounters per 1,000 people (2.4% of encounters) in Wake County to 30.1 encounters per 1,000 people (6.4%) in Orange County. LIMITATIONS: There is a possibility of nondifferential classification error in the state databases, as coding practices and coding errors may vary between facilities. We were unable to confirm diagnoses through additional clinical information or Diagnostic and Statistical Manual criteria. CONCLUSION: Mental health and substance misuse-related encounters constitute a small percentage of emergency department encounters in North Carolina's urban counties, with significant variation between counties. Diverting some of these encounters to community-based mental health and substance misuse health care providers could reduce emergency department utilization while improving the quality of care delivered to this vulnerable patient population.

Cachexia & debility diagnoses in hospitalized children and adolescents with complex chronic conditions: evidence from the Kids' Inpatient Database.

OBJECTIVE: To characterize the frequency, cost, and hospital-reported outcomes of cachexia and debility in children and adolescents with complex chronic conditions (CCCs). METHODS: We identified children and adolescents (aged ≤20 years) with CCCs, cachexia, and debility in the Kids' Inpatient Database [Healthcare Cost and Utilization Project, Agency for Healthcare Research & Quality]. We then compared the characteristics of patients and hospitalizations, including cost and duration of stay, for CCCs with and without cachexia and/or debility. We examined factors that predict risk of inpatient mortality in children and adolescents with CCCs using a logistic regression model. We examined factors that impact duration of stay and cost in children and adolescents with CCCs using negative binomial regression models. All costs are reported in US dollars in 2014 using Consumer Price Index inflation adjustment. RESULTS: We estimated the incidence of hospitalization of cachexia in children and adolescents with CCCs at 1,395 discharges during the sample period, which ranged from 277 discharges in 2003 to 473 discharges in 2012. We estimated the incidence of hospitalization due to debility in children and adolescents with CCCs at 421 discharges during the sample period, which ranged from 39 discharges in 2003 to 217 discharges in 2012. Cachexia was associated with a 60% increase in the risk of inpatient mortality, whereas debility was associated with a 40% decrease in the risk of mortality. Cachexia and debility increased duration of stay in hospital (17% and 39% longer stays, respectively). Median cost of hospitalization was $15,441.59 and $23,796.16 for children and adolescents with cachexia and debility, respectively. CONCLUSIONS: Incidence of hospitalization for cachexia in children and adolescents with CCCs is less than that for adults but the frequency of cachexia diagnoses increased over time. Estimates of the incidence of hospitalization with debility in children and adolescents with CCCs have not been reported, but our study demonstrates that the frequency of these discharges is also increasing.

One-year prevalence, comorbidities and cost of cachexia-related inpatient admissions in the USA.

BACKGROUND: Cachexia is a condition characterized as a loss in body mass or metabolic dysfunction and is associated with several prevalent chronic health conditions including many cancers, COPD, HIV, and kidney disease, with between 10 and 50% of patients with these conditions having cachexia. Currently there is little research into cachexia and our objective is to characterize cachexia patients, their healthcare utilization, and associated hospitalization costs. Given the increasing prevalence of chronic diseases, it is important to better understand cachexia so that the condition can be better diagnosed and managed. METHODS: We utilized one year (2009) of the Nationwide Inpatient Sample (NIS). The NIS represents all inpatient stays at a random 20% sample of all hospitals within the United States. We grouped cachexia individuals by primary or secondary discharge diagnosis and then compared those with cachexia to all others in terms of length of stay (LOS) and total cost. Finally we looked into factors predicting increased LOS using a negative binomial model. RESULTS: We estimated US prevalence for cachexia-related inpatient admissions at 161,898 cases. Cachexia patients were older, with an average age of 67.95 versus 48.10 years in their non-cachexia peers. Hospitalizations associated with cachexia had an increased LOS compared to non-cachexia patients (6 versus 3 days), with average costs per stay $4641.30 greater. Differences were seen in loss of function (LOF) with cachexia patients, mostly in the major LOF category (52.60%), whereas non-cachexia patients were spread between minor, moderate, and major LOF (36.28%, 36.11%, and 21.26%, respectively). Significant positive predictors of increased LOS among cachexia patients included urban hospital (IRR=1.21, non-teaching urban; IRR=1.23, teaching urban), having either major (IRR=1.41) or extreme (IRR=2.64) LOF, and having a primary diagnosis of pneumonia (IRR=1.15). CONCLUSION: We have characterized cachexia and seen it associated with increased length of stay, increased cost, and more severe loss of function in patients compared to those without cachexia.