Total knee arthroplasty (TKA) is one of the most common and costly surgical procedures performed in the United States.
To examine longitudinal trends in volume, utilization, and outcomes for primary ...and revision TKA between 1991 and 2010 in the US Medicare population.
Observational cohort of 3,271,851 patients (aged ≥65 years) who underwent primary TKA and 318 563 who underwent revision TKA identified in Medicare Part A data files.
We examined changes in primary and revision TKA volume, per capita utilization, hospital length of stay (LOS), readmission rates, and adverse outcomes.
Between 1991 and 2010 annual primary TKA volume increased 161.5% from 93,230 to 243,802 while per capita utilization increased 99.2% (from 31.2 procedures per 10,000 Medicare enrollees in 1991 to 62.1 procedures per 10,000 in 2010). Revision TKA volume increased 105.9% from 9650 to 19,871 while per capita utilization increased 59.4% (from 3.2 procedures per 10,000 Medicare enrollees in 1991 to 5.1 procedures per 10,000 in 2010). For primary TKA, LOS decreased from 7.9 days (95% CI, 7.8-7.9) in 1991-1994 to 3.5 days (95% CI, 3.5-3.5) in 2007-2010 (P < .001). For primary TKA, rates of adverse outcomes resulting in readmission remained stable between 1991-2010, but rates of all-cause 30-day readmission increased from 4.2% (95% CI, 4.1%-4.2%) to 5.0% (95% CI, 4.9%-5.0%) (P < .001). For revision TKA, the decrease in hospital LOS was accompanied by an increase in all-cause 30-day readmission from 6.1% (95% CI, 5.9%-6.4%) to 8.9% (95% CI, 8.7%-9.2%) (P < .001) and an increase in readmission for wound infection from 1.4% (95% CI, 1.3%-1.5%) to 3.0% (95% CI, 2.9%-3.1%) (P < .001).
Increases in TKA volume have been driven by both increases in the number of Medicare enrollees and in per capita utilization. We also observed decreases in hospital LOS that were accompanied by increases in hospital readmission rates.
Abstract Recently, the government has moved towards public reporting of 30-day readmission rates after elective primary total knee (TKA) and total hip arthroplasty (THA). We identified 11,814 and ...8105 patients who underwent primary TKA and THA from the 2011 ACS NSQIP. Overall readmission rates within 30-days of surgery were 4.6% for TKA and 4.2% for THA. Complications associated with readmission were predominantly wound infections, sepsis, thromboembolic, cardiac, and respiratory related. In TKA, multivariate analysis identified age ( P = 0.002), male gender ( P = 0.03), cancer history ( P = 0.008), elevated BUN ( P = 0.002), a bleeding disorder ( P < 0.001) and high ASA class ( P < 0.001) as predictors of readmission. In THA, obesity ( P = 0.008), steroid use ( P = 0.037), a bleeding disorder ( P = 0.002), dependent functional status ( P = 0.022), and high ASA class ( P < 0.001) predicted readmission. Understanding characteristics associated with readmission will be essential for equitable patient risk stratification.
The COVID-19 pandemic has led to a notable increase in telemedicine adoption. However, the impact of the pandemic on telemedicine use at a population level in rural and remote settings remains ...unclear.
This study aimed to evaluate changes in the rate of telemedicine use among rural populations and identify patient characteristics associated with telemedicine use prior to and during the pandemic.
We conducted a repeated cross-sectional study on all monthly and quarterly rural telemedicine visits from January 2012 to June 2020, using administrative data from Ontario, Canada. We compared the changes in telemedicine use among residents of rural and urban regions of Ontario prior to and during the pandemic.
Before the pandemic, telemedicine use was steadily low in 2012-2019 for both rural and urban populations but slightly higher overall for rural patients (11 visits per 1000 patients vs 7 visits per 1000 patients in December 2019, P<.001). The rate of telemedicine visits among rural patients significantly increased to 147 visits per 1000 patients in June 2020. A similar but steeper increase (P=.15) was observed among urban patients (220 visits per 1000 urban patients). Telemedicine use increased across all age groups, with the highest rates reported among older adults aged ≥65 years (77 visits per 100 patients in 2020). The proportions of patients with at least 1 telemedicine visit were similar across the adult age groups (n=82,246/290,401, 28.3% for patients aged 18-49 years, n=79,339/290,401, 27.3% for patients aged 50-64 years, and n=80,833/290,401, 27.8% for patients aged 65-79 years), but lower among younger patients <18 years (n=23,699/290,401, 8.2%) and older patients ≥80 years (n=24,284/290,401, 8.4%) in 2020 (P<.001). There were more female users than male users of telemedicine (n=158,643/290,401, 54.6% vs n=131,758/290,401, 45.4%, respectively, in 2020; P<.001). There was a significantly higher proportion of telemedicine users residing in relatively less rural than in more rural regions (n=261,814/290,401, 90.2% vs n=28,587/290,401, 9.8%, respectively, in 2020; P<.001).
Telemedicine adoption increased in rural and remote areas during the COVID-19 pandemic, but its use increased in urban and less rural populations. Future studies should investigate the potential barriers to telemedicine use among rural patients and the impact of rural telemedicine on patient health care utilization and outcomes.
Patients with acute heart failure are frequently or systematically hospitalized, often because the risk of adverse events is uncertain and the options for rapid follow-up are inadequate. Whether the ...use of a strategy to support clinicians in making decisions about discharging or admitting patients, coupled with rapid follow-up in an outpatient clinic, would affect outcomes remains uncertain.
In a stepped-wedge, cluster-randomized trial conducted in Ontario, Canada, we randomly assigned 10 hospitals to staggered start dates for one-way crossover from the control phase (usual care) to the intervention phase, which involved the use of a point-of-care algorithm to stratify patients with acute heart failure according to the risk of death. During the intervention phase, low-risk patients were discharged early (in ≤3 days) and received standardized outpatient care, and high-risk patients were admitted to the hospital. The coprimary outcomes were a composite of death from any cause or hospitalization for cardiovascular causes within 30 days after presentation and the composite outcome within 20 months.
A total of 5452 patients were enrolled in the trial (2972 during the control phase and 2480 during the intervention phase). Within 30 days, death from any cause or hospitalization for cardiovascular causes occurred in 301 patients (12.1%) who were enrolled during the intervention phase and in 430 patients (14.5%) who were enrolled during the control phase (adjusted hazard ratio, 0.88; 95% confidence interval CI, 0.78 to 0.99; P = 0.04). Within 20 months, the cumulative incidence of primary-outcome events was 54.4% (95% CI, 48.6 to 59.9) among patients who were enrolled during the intervention phase and 56.2% (95% CI, 54.2 to 58.1) among patients who were enrolled during the control phase (adjusted hazard ratio, 0.95; 95% CI, 0.92 to 0.99). Fewer than six deaths or hospitalizations for any cause occurred in low- or intermediate-risk patients before the first outpatient visit within 30 days after discharge.
Among patients with acute heart failure who were seeking emergency care, the use of a hospital-based strategy to support clinical decision making and rapid follow-up led to a lower risk of the composite of death from any cause or hospitalization for cardiovascular causes within 30 days than usual care. (Funded by the Ontario SPOR Support Unit and others; COACH ClinicalTrials.gov number, NCT02674438.).
The coronavirus disease 2019 (COVID-19) pandemic is thought to have increased use of virtual care, but population-based studies are lacking. We aimed to assess the uptake of virtual care during the ...COVID-19 pandemic using comprehensive population-based data from Ontario.
This was a repeated cross-sectional study design. We used administrative data to evaluate changes in in-person and virtual visits among all residents of Ontario before (2012-2019) and during (January-August 2020) the COVID-19 pandemic. We included all patients who had an ambulatory care visit in Ontario. We excluded claims for patients who were not Ontario residents or had an invalid or missing health card number. We compared monthly or quarterly virtual care use across age groups, neighbourhood income quintiles and chronic disease subgroups. We also examined physician characteristics that may have been associated with virtual care use.
Among all residents of Ontario (population 14.6 million), virtual care increased from 1.6% of total ambulatory visits in the second quarter of 2019 to 70.6% in the second quarter of 2020. The proportion of physicians who provided 1 or more virtual visits per year increased from 7.0% in the second quarter of 2019 to 85.9% in the second quarter of 2020. The proportion of Ontarians who had a virtual visit increased from 1.3% in 2019 to 29.2% in 2020. Older patients were the highest users of virtual care. The proportion of total virtual visits that were provided to patients residing in rural areas (v. urban areas) declined significantly between 2012 and 2020, reflecting a shift in virtual care to a service increasingly used in urban centres. The rates of virtual care use increased similarly across all conditions and across all income quintiles.
Our findings show that Ontario's approach to virtual care led to broad adoption across all provider groups, patient age, types of chronic diseases and neighborhood income. These findings have policy implications, including use of virtual care billing codes, for the ongoing use of virtual care during the second wave of the pandemic and beyond.
A retrospective cohort study.
The aim of this study was to examine variation in spine surgery utilization between the province of Ontario and state of New York among all patients and pre-specified ...patient subgroups.
Spine surgery is common and costly. Within-country variation in utilization is well studied, but there has been little exploration of variation in spine surgery utilization between countries.
We used population-level administrative data from Ontario (years 2011-2015) and New York (2011-2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery using relevant procedure codes. Patients were stratified according to age and surgical urgency (elective vs. emergent). We calculated standardized utilization rates (procedures per-10,000 population per year) for each jurisdiction. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared utilization rates of spinal decompression and fusion surgery in Ontario and New York among all patients and after stratifying by surgical urgency and patient age.
Patients in Ontario were older than patients in New York for both decompression (mean age 58.8 vs. 51.3 years; P < 0.001) and fusion (58.1 vs. 54.9; P < 0.001). A smaller percentage of hospitals in Ontario than New York performed decompression (26.1% vs. 54.9%; P < 0.001) or fusion (15.2% vs. 56.7%; P < 0.001). Overall, utilization of spine surgery (decompression plus fusion) in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 16.5 per-10,000 per-year (P < 0.001). Ontario-New York differences in utilization were smaller for emergent cases (2.0 per 10,000 in Ontario vs. 2.5 in New York; P < 0.001), but larger for elective cases (4.6 vs. 13.9; P < 0.001). The lower utilization in Ontario was particularly large among younger patients (age <60 years).
We found significantly lower utilization of spine surgery in Ontario than in New York. These differences should inform policy reforms in both jurisdictions.
3.
It is currently unclear how the shift towards virtual care during the 2019 novel coronavirus (COVID-19) pandemic may have impacted chronic disease management at a population level. The goals of our ...study were to provide a description of the levels of use of virtual care services relative to in-person care in patients with chronic disease across Ontario, Canada and to describe levels of healthcare utilization in low versus high virtual care users.
We used linked health administrative data to conduct a population-based, repeated cross-sectional study of all ambulatory patient visits in Ontario, Canada (January 1, 2018 to January 16, 2021). Further stratifications were also completed to examine patients with COPD, heart failure, asthma, hypertension, diabetes, mental illness, and angina. Patients were classified as low (max 1 virtual care visit) vs. high virtual care users. A time-series analysis was done using interventional autoregressive integrated moving average (ARIMA) modelling on weekly hospitalizations, outpatient visits, and diagnostic tests.
The use of virtual care increased across all chronic disease patient populations. Virtual care constituted at least half of the total care in all conditions. Both low and high virtual care user groups experienced a statistically significant reduction in hospitalizations and laboratory testing at the start of the pandemic. Hospitalization volumes increased again only among the high users, while testing increased in both groups. Outpatient visits among high users remained unaffected by the pandemic but dropped in low users.
The decrease of in-person care during the pandemic was accompanied by an increase in virtual care, which ultimately allowed patients with chronic disease to return to the same visit rate as they had before the onset of the pandemic. Virtual care was adopted across various chronic conditions, but the relative adoption of virtual care varied by condition with highest rates seen in mental health.
It is unknown whether previously reported disparities for acute myocardial infarction (AMI) by race and sex have declined over time.
We used Medicare Part A administrative data files for 1992 to 2010 ...to evaluate changes in per-capita hospitalization rates for AMI, rates of revascularization (percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)), and 30-day mortality for four distinct patient subcohorts: black women; black men; white women; and white men, adjusted for age, comorbidities and year using logistic regression.
The study sample consisted of 4,045,267 AMI admissions between the years 1992 and 2010 (166,660 black women; 116,201 black men; 1,870,816 white women; 1,891,590 white men). AMI hospitalization rates differed significantly in 1992 to 1993 among black women (61.6 hospitalizations per 10,000 Medicare enrollees), black men (73.2 hospitalizations), white women (72.0 hospitalizations) and white men (113.2 hospitalizations) (P<0.0001). By 2009 to 2010 AMI hospitalization rates had declined substantially in all cohorts but disparities remained with significantly lower hospitalization rates among women and blacks compared to men and whites, respectively (P<0.0001). In multivariable-adjusted analyses, despite narrowing of the differences between cohorts over time, disparities in AMI hospitalization rates by race and sex remained statistically significant in 2009 to 2010 (P<0.001). In 1992 to 1993 and 2009 to 2010, rates of PCI within 30-days of AMI differed significantly among black women (8.6% in 1992 to 1993; 24.2% in 2009 to 2010), black men (10.4% and 32.6%), white women (12.8% and 30.5%), and white men (16.1% and 40.7%) (P<0.0001). In multivariable-adjusted analyses, racial disparities in procedure utilization appeared somewhat larger and sex-based disparities remained significant. Unadjusted 30-day mortality after AMI in 1992 to 1993 for black women, black men, white women and white men was 20.4%, 17.9%, 23.1% and 19.5%, respectively (P<0.0001); in 2009 to 2010 mortality was 17.1%, 15.3%, 18.2% and 16.2%, respectively (P<0.0001). In adjusted analyses, racial differences in mortality declined over time but differences by sex (higher mortality for women) persisted.
Disparities in AMI have declined modestly, but remain a problem, particularly with respect to patient sex.
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