Objective: We sought to examine whether the outcomes of patients who receive a surgical procedure on Friday the 13th differ from patients who receive surgery on flanking Fridays. Background: Numerous ...studies have demonstrated that increased anxiety from the provider or patient around the time of surgery can lead to worse outcomes. Superstitious patients often express significant concern and anxiety when undergoing a surgical procedure on Friday the 13th. Methods: A retrospective, population-based cohort study of 19,747 adults undergoing 1 of 25 common surgical procedures on Friday the 13th or flanking control Fridays (Friday the 6th and Friday the 20th) between January 1, 2007, and December 31, 2019, with 1 year of follow-up. The main outcomes included death, readmission, and complications at 30 days (short-term), 90 days (intermediate-term), and 1 year (long-term). Results: A total of 7,349 (37.2%) underwent surgery on Friday the 13th, and 12,398 (62.8%) underwent surgery on a flanking Friday during the study period. Patient characteristics were similar between the 2 groups. We found no evidence that patients receiving surgery on Friday the 13th group were more likely to experience the composite primary outcome at 30 days adjusted odds ratio (aOR) = 1.02 (95% CI = 0.94–1.09), 90 days aOR = 0.97 (95% CI = 0.90–1.04), and 1 year aOR = 0.99 (95% CI = 0.94–1.04) after surgery. Conclusion: Patients receiving surgery on Friday the 13th do not appear to fare worse than those treated on ordinary Fridays with respect to the composite outcome.
The objective of this study was to examine the impact of pedestrian countdown signals (PCS) on the rate of motor vehicle collisions (MVCs) in Toronto, Canada. A quasi-experimental design was used to ...compare rates of single and two vehicle MVCs before and after installation of PCS in Toronto, Canada between January 2005 and December 2009. Collision incidence rates were compared using Poisson regression analyses with adjustment for relevant cofounders and reported as incidence rate ratios (IRR) with 95% confidence intervals (CI). Secondary analyses were performed on subsets of collisions by collision type and injury severity. A total of 94,175 MVCs occurred at or near 1965 intersections at which PCS were installed over the five-year study period. Overall, the MVC incidence rate increased 7.5% (IRR = 1.075; 95% CI: 1.042-1.109; p < 0.0001) after installation of PCS. The installation of PCS led to an increase in MVCs. PCS may have an unintended consequence of increasing the rate of MVCs.
Celotno besedilo
Dostopno za:
BFBNIB, DOBA, GIS, IJS, IZUM, KILJ, KISLJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
To estimate the 1) accuracy of algorithms for identifying osteoarthritis (OA) using health administrative data; and 2) population-level OA prevalence and incidence over time in Ontario, Canada.
We ...performed a retrospective chart abstraction study to identify OA patients in a random sample of 7500 primary care patients from electronic medical records. The validation sample was linked with several administrative data sources. Accuracy of administrative data algorithms for identifying OA was tested against two reference standard definitions by estimating the sensitivity, specificity and predictive values. The validated algorithms were then applied to the Ontario population to estimate and compare population-level prevalence and incidence from 2000 to 2017.
OA prevalence within the validation sample ranged from 10% to 23% across the two reference standards. Algorithms varied in accuracy depending on the reference standard, with the sensitivity highest (77%) for patients with OA documented in medical problem lists. Using the top performing administrative data algorithms, the crude population-level OA prevalence ranged from 11% to 25% and standardized prevalence ranged from 9 to 22% in 2017. Over time, prevalence increased whereas incidence remained stable (~1% annually).
Health administrative data have limited sensitivity in adequately identifying all OA patients and appear to be more sensitive at detecting OA patients for whom their physician formally documented their diagnosis in medical problem lists than individuals who have their diagnosis documented outside of problem lists. Irrespective of the algorithm used, OA prevalence has increased over the past decade while annual incidence has been stable.
IMPORTANCE: Surgeon sex is associated with differential postoperative outcomes, though the mechanism remains unclear. Sex concordance of surgeons and patients may represent a potential mechanism, ...given prior associations with physician-patient relationships. OBJECTIVE: To examine the association between surgeon-patient sex discordance and postoperative outcomes. DESIGN, SETTING, AND PARTICIPANTS: In this population-based, retrospective cohort study, adult patients 18 years and older undergoing one of 21 common elective or emergent surgical procedures in Ontario, Canada, from 2007 to 2019 were analyzed. Data were analyzed from November 2020 to March 2021. EXPOSURES: Surgeon-patient sex concordance (male surgeon with male patient, female surgeon with female patient) or discordance (male surgeon with female patient, female surgeon with male patient), operationalized as a binary (discordant vs concordant) and 4-level categorical variable. MAIN OUTCOMES AND MEASURES: Adverse postoperative outcome, defined as death, readmission, or complication within 30-day following surgery. Secondary outcomes assessed each of these metrics individually. Generalized estimating equations with clustering at the level of the surgical procedure were used to account for differences between procedures, and subgroup analyses were performed according to procedure, patient, surgeon, and hospital characteristics. RESULTS: Among 1 320 108 patients treated by 2937 surgeons, 602 560 patients were sex concordant with their surgeon (male surgeon with male patient, 509 634; female surgeon with female patient, 92 926) while 717 548 were sex discordant (male surgeon with female patient, 667 279; female surgeon with male patient, 50 269). A total of 189 390 patients (14.9%) experienced 1 or more adverse postoperative outcomes. Sex discordance between surgeon and patient was associated with a significant increased likelihood of composite adverse postoperative outcomes (adjusted odds ratio aOR, 1.07; 95% CI, 1.04-1.09), as well as death (aOR, 1.07; 95% CI, 1.02-1.13), and complications (aOR, 1.09; 95% CI, 1.07-1.11) but not readmission (aOR, 1.02; 95% CI, 0.98-1.07). While associations were consistent across most subgroups, patient sex significantly modified this association, with worse outcomes for female patients treated by male surgeons (compared with female patients treated by female surgeons: aOR, 1.15; 95% CI, 1.10-1.20) but not male patients treated by female surgeons (compared with male patients treated by male surgeons: aOR, 0.99; 95% CI, 0.95-1.03) (P for interaction = .004). CONCLUSIONS AND RELEVANCE: In this study, sex discordance between surgeons and patients negatively affected outcomes following common procedures. Subgroup analyses demonstrate that this is driven by worse outcomes among female patients treated by male surgeons. Further work should seek to understand the underlying mechanism.
Objective
Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are based on patients with osteoarthritis (OA); less is known about ...outcomes in rheumatoid arthritis (RA). Using a validated algorithm for identifying patients with RA, we undertook this study to compare the rates of complications among THA and TKA recipients between those with RA and those without RA.
Methods
In patients who underwent a first primary elective THA or TKA between 2002 and 2009, those with RA were identified using a validated algorithm: a hospitalization with a diagnosis code for RA or 3 physician billing claims with a diagnosis code for RA, with at least 1 claim by a specialist (rheumatologist, orthopedic surgeon, or internist) in a 2‐year period. Recipients with diagnostic codes suggesting an inflammatory arthritis, but not meeting RA criteria, were classified as having inflammatory arthritis. All remaining patients were deemed to have OA. Cox proportional hazards models, censored on death, were used to determine the relationship between the type of arthritis and the occurrence of specific complications, adjusting for potential confounders (age, sex, comorbidity, and provider volume).
Results
We identified 43,997 eligible THA recipients (3% with RA) and 71,793 eligible TKA recipients (4% with RA). Total joint arthroplasty recipients with RA had higher age and sex–standardized rates of dislocation following THA (2.45%, compared with 1.21% for recipients with OA) and higher age and sex–standardized rates of infection following TKA (1.26%, compared with 0.84% for recipients with OA). Controlling for potential confounders, recipients with RA remained at increased risk of dislocation within 2 years of THA (adjusted hazard ratio HR 1.91, P = 0.001) and remained at increased risk of infection within 2 years of TKA (adjusted HR 1.47, P = 0.03) relative to recipients with OA.
Conclusion
Patients with RA are at higher risk of dislocation following THA and are at higher risk of infection following TKA relative to those with OA. Further research is warranted to elucidate explanations for these findings, including the roles of medication profile, implant choice, postoperative antibiotic protocol, and method of rehabilitation following joint replacement.
Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could ...reduce mortality and major complications.
HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896).
Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (−1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (−2 to 4; p=0·71).
Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.
Canadian Institutes of Health Research.
The objective of this review is to examine the effect of perioperative systemic corticosteroids at varying doses and timings on early postoperative recovery outcomes following unilateral total knee ...and total hip arthroplasty. The primary outcome was length of stay (LOS).
A systematic review and meta-analysis of randomized controlled trials was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to June 1, 2020. Studies comparing the outcome of adult patients receiving a systemic steroid to patients who did not receive steroids were included.
Seventeen studies were included, incorporating 1957 patients. Perioperative corticosteroids reduced hospital LOS (mean difference MD = −0.39 days, 95% confidence interval CI −0.61 to −0.18). A subsequent dose of corticosteroid at 24 hours further reduced LOS (MD = −0.33, 95% CI −0.55 to −0.11). Corticosteroids resulted in reduced levels of pain on postoperative day (POD) 0 (MD = −1.99, 95% CI −3.30 to −0.69), POD1 (MD = −1.47, 95% CI −2.15 to −0.79), and POD2. Higher doses were more effective in reducing pain with activity on POD0 (P = .006) and 1 (P = .023). Steroids reduced the incidence of PONV on POD1 (log odds ratio OR = −1.05, 95% CI −1.26 to −0.84) and POD2, with greater effect at higher doses (P = .046). Corticosteroids did not increase the incidence of infection (P = 1.000), venous thromboembolism (P = 1.000), or gastrointestinal hemorrhage (P = 1.000) but were associated with an increase in blood glucose (MD = 5.30 mg/dL, 95% CI 2.69-7.90).
Perioperative corticosteroids are safe, facilitate earlier discharge, and improve patient recovery following unilateral total knee arthroplasty and total hip arthroplasty. Higher doses (15-20 mg of dexamethasone) are associated with further reductions in dynamic pain and PONV, and repeat dosing may further reduce LOS.
The relationship between sex and outcomes, especially complications, after total hip arthroplasty (THA) has not been well established. This study aimed to identify if patient biological sex ...significantly impacted complications after THA in Ontario, Canada.
A population-based retrospective cohort study of patients undergoing primary THA in Ontario from April 1, 2015 to March 31, 2020 was conducted. The primary outcome was major surgical complications within a year postsurgery (a composite of revision, deep infection requiring surgery, and dislocation). Secondary outcomes included the individual component of the composite primary outcome and major medical complications within 30 days. Proportional hazards regression calculated the adjusted hazards ratio for major surgical complications in men relative to women, adjusting for age, comorbidities, neighborhood income quintile, surgeon and hospital volume, and year of surgery.
A total of 67,077 patients (median age 68 years; 54.1% women) from 61 hospitals were included; women were older with a higher prevalence of frailty. Women had a higher rate of major surgical complications within 1 year of surgery compared to men (2.9 versus 2.5%, adjusted odds ratio 1.19, 95% confidence interval 1.08 to 1.33, P = .0009). Conversely, men had a higher risk for medical complications within 30 days (6.3 versus 2.7%, P < .001).
Observable sex disparities exist in post-THA complications; women face surgical complications predominantly, while medical complications are more prevalent in men. These insights can shape preoperative patient consultations.
Level III.
Recent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of ...primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty.
PubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means.
Twenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits.
ED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.
PDF
