Abstract Background As opioid use increases nationally, the arthroplasty surgeon is likely to see more patients taking opioid analgesics on initial presentation. The purpose of this study was to ...investigate the use of opiate medication in the preoperative and postoperative patient undergoing primary total joint arthroplasty. Methods From October 2010 to November 2011, data on 367 consecutive patients who underwent primary total joint arthroplasty were reviewed. Using the Michigan Automated Prescription System database, data were collected on opiate use from 3 months preop to 12 months postop. Patients were grouped by preoperative opiate use. Patients with ≥2 opiate prescriptions filled per 6-week period before surgery were considered chronic opiate users. Results Three hundred fifteen patients fit our inclusion/exclusion criteria. There were 158 primary total knee and 157 primary total hip arthroplasty patients. At 1 year after operation, 64% of chronic opiate users were still being prescribed opiates compared with 22% of the control group ( P < .001). Thirty-one percent of the chronic opiate users were discharged to an extended care facility compared to 21% of the control group ( P = .123). Of all the opiate prescriptions, 77% were written by a practitioner other than the surgeon. Conclusions Opiates are frequently prescribed by providers other than the surgeon preoperatively and postoperatively. The use of opiates that were presumably prescribed to treat joint pain was continued for more than 1 year postoperatively in 64% of cases. Patients taking multiple opiates or more potent opiates preoperatively filled more prescriptions postoperatively. Chronic use of opiates negatively influenced the discharge disposition.
Abstract Background Recent health care policy changes require hospitals and physicians to demonstrate improved quality. In 2012, a prospective database was formed with the Blue Cross and Blue Shield ...of Michigan to improve quality of care. The purpose of this study was to analyze patient preoperative medication as predictors of outcomes after total joint arthroplasty. Methods Data were collected on patient's preoperative medications from 2012 to 2015 using a total joint arthroplasty database. Medications were categorized as antiplatelet, antimicrobial, anticoagulant, narcotic, steroid, insulin, or oral diabetes medication. Outcomes included hospital length of stay (LOS), discharge disposition/destination, and 90-day readmission. Univariate and multivariate regression analyses were performed. Results A total of 3959 patients were studied. Eighty percent (3163 patients) were discharged home. The remainder (795) went to an extended-care facility (ECF). Patients discharged to an ECF were taking more medications (1.13 vs 0.80 in total knee arthroplasty; 1.18 vs 0.83 in total hip arthroplasty; P <.001). Patients who were readmitted took more medications (1.0 vs 0.85; P <.01). There were more discharges to an ECF in narcotic, steroid, and diabetes medication users. Patients taking anticoagulants, narcotics, insulin, and antiplatelets had greater readmission rates. There was a significant correlation between the number of medications and an increased LOS. Conclusion Patients taking more medications were more frequently discharged to an ECF and had increased LOS and readmission rates. Narcotics and diabetic medications had the greatest influence. Category and quantity of preoperative medications can be used as predictors of outcomes after arthroplasty surgery.
There are significant variations in transfusion rates among institutions performing total joint arthroplasty. We previously demonstrated that implementation of an educational program to increase ...awareness of the American Association of Blood Banks’ transfusion guidelines led to an immediate decrease in transfusion rates at our facilities. It remained unclear how this initiative would endure over time. We report the long-term success and sustainability of this quality program.
We reviewed the Michigan Arthroplasty Collaborative Quality Initiative data from 2012 through 2017 of all patients undergoing primary hip and knee arthroplasty at our institutions for preoperative and postoperative hemoglobin level, transfusion status, and number of units transfused and transfusions outside of protocol to identify changes surrounding our blood transfusion educational initiative. We calculated the transfusions prevented and cost implications over the course of the study.
We identified 6645 primary hip and knee arthroplasty patients. There was a significant decrease in transfusion rate and overall transfusions in each group when compared to pre-education values. Subgroup analysis of TKA and THA independently showed significant decreases in both transfusion rate and overall transfusions. Over the final 3 years of the study, only 2 patients were transfused outside of the American Association of Blood Banks protocol. We estimate prevention of 519 transfusions over the study period.
Application of this quality initiative was an effective means of identifying opportunities for quality improvement. The program was easily initiated, had significant early impact, and has been shown to be sustainable.
ABSTRACT
BACKGROUND
Although benefits of performance measurement (PM) systems have been well documented, there is little research on negative unintended consequences of performance measurement ...systems in primary care. To optimize PM systems, a better understanding is needed of the types of negative unintended consequences that occur and of their causal antecedents.
OBJECTIVES
(1) Identify unintended negative consequences of PM systems for patients. (2) Develop a conceptual framework of hypothesized relationships between PM systems, facility-level variables (local implementation strategies, primary care staff attitudes and behaviors), and unintended negative effects on patients.
DESIGN, PARTICIPANTS, APPROACH
Qualitative study design using dissimilar cases sampling. A series of 59 in-person individual semi-structured interviews at four Veterans Health Administration (VHA) facilities was conducted between February and July 2009. Participants included members of primary care staff and facility leaders. Sites were selected to assure variability in the number of veterans served and facility scores on national VHA performance measures. Interviews were recorded, transcribed and content coded to identify thematic categories and relationships.
RESULTS
Participants noted both positive effects and negative unintended consequences of PM. We report three negative unintended consequences for patients. Performance measurement can (1) lead to inappropriate clinical care, (2) decrease provider focus on patient concerns and patient service, and (3) compromise patient education and autonomy. We also illustrate examples of negative consequences on primary care team dynamics. In many instances these problems originate from local implementation strategies developed in response to national PM definitions and policies.
CONCLUSIONS
Facility-level strategies undertaken to implement national PM systems may result in inappropriate clinical care, can distract providers from patient concerns, and may have a negative effect on patient education and autonomy. Further research is needed to ascertain how features of centralized PM systems influence whether measures are translated locally by facilities into more or less patient-centered policies and processes.
Quality Improvement (QI) throughout health care in the United States continues to be of growing importance to both patients and providers. Leaders in health care including physicians, nurses, ...hospital administrators, and payors are all responsible for ensuring the continuation and growth of QI initiatives. This article will discuss various ways that healthcare leaders, with specific regard to orthopedic surgery, have utilized QI measures to provide better, more efficient, care to patients.
We report on the measurement of the γp→J/ψp cross section from E_{γ}=11.8 GeV down to the threshold at 8.2 GeV using a tagged photon beam with the GlueX experiment. We find that the total cross ...section falls toward the threshold less steeply than expected from two-gluon exchange models. The differential cross section dσ/dt has an exponential slope of 1.67±0.39 GeV^{-2} at 10.7 GeV average energy. The LHCb pentaquark candidates P_{c}^{+} can be produced in the s channel of this reaction. We see no evidence for them and set model-dependent upper limits on their branching fractions B(P_{c}^{+}→J/ψp) and cross sections σ(γp→P_{c}^{+})×B(P_{c}^{+}→J/ψp).
The purpose of this study was to determine whether there is an increase in expression of bcl-2 and related bcl-2 gene family members bcl-X and bax in liver biopsy samples obtained from patients with ...either hepatitis C infection or cirrhosis. Bcl-2, bcl-X, and bax, as well as other bcl-2-related proteins, function coordinately through homo- and heterodimerization to regulate apoptosis. Bcl-2, which is characterized as an antiapoptotic, also functions as an antioxidant. We hypothesized that a mechanism that could account for increased hepatocellular carcinoma in patients with hepatitis C and cirrhosis is selection of bcl-2 expressing cells. This selection would be due to the capacity of individual cells to resist the toxic effects of inflammatory byproducts, specifically reactive oxygen species.
Sections cut from archived liver biopsy samples embedded in paraffin were probed with antibody specific for bcl-2, bcl-X, or bax. Liver samples were from normal (N = 5), hepatitis C patients (N = 19), and cirrhotics (N = 10). Percent positive staining and intensity of staining were judged independently for hepatocytes, bile ducts, mononuclear cells, and Kupffer cells.
Bcl-2 expression was evident in bile ducts and mononuclear cells of hepatitis C patients, but was not commonly present in hepatocytes (two of 10). In the cirrhotic liver, bcl-2 expression was also detected in bile ducts and mononuclear cells, but in contrast to hepatitis patients was also expressed in hepatocytes (nine of 10). A similar pattern of expression was evident for bcl-X, but in general the level of expression was limited relative to that of bcl-2. Bax expression was infrequently present in sections from any of the three patient groups.
The data indicate that bcl-2 expression is elevated in the liver of cirrhotics, but is not evident in the liver of hepatitis C patients. This increase in expression of bcl-2 in cirrhotic patients may correlate with development of hepatocellular carcinoma given the anti-apoptotic/oncogenic potential of bcl-2.
Here, we report the total and differential cross sections for $J/\psi$ photoproduction with the large acceptance GlueX spectrometer for photon beam energies from the threshold at 8.2 GeV up to 11.44 ...GeV and over the full kinematic range of momentum transfer squared, $t$. Such coverage facilitates the extrapolation of the differential cross sections to the forward ($t = 0$) point beyond the physical region. The forward cross section is used by many theoretical models and plays an important role in understanding $J/\psi$ photoproduction and its relation to the $J/\psi$-proton interaction. These measurements of $J/\psi$ photoproduction near threshold are also crucial inputs to theoretical models that are used to study important aspects of the gluon structure of the proton, such as the gluon Generalized Parton Distribution (GPD) of the proton, the mass radius of the proton, and the trace anomaly contribution to the proton mass. We observe possible structures in the total cross section energy dependence and find evidence for contributions beyond gluon exchange in the differential cross section close to threshold, both of which are consistent with contributions from open-charm intermediate states.
The GlueX beamline and detector Akondi, C.S.; Barbosa, F.; Barsotti, R. ...
Nuclear instruments & methods in physics research. Section A, Accelerators, spectrometers, detectors and associated equipment,
01/2021, Volume:
987
Journal Article
Peer reviewed
Open access
The GlueX experiment at Jefferson Lab has been designed to study photoproduction reactions with a 9-GeV linearly polarized photon beam. The energy and arrival time of beam photons are tagged using a ...scintillator hodoscope and a scintillating fiber array. The photon flux is determined using a pair spectrometer, while the linear polarization of the photon beam is determined using a polarimeter based on triplet photoproduction. Charged-particle tracks from interactions in the central target are analyzed in a solenoidal field using a central straw-tube drift chamber and six packages of planar chambers with cathode strips and drift wires. Electromagnetic showers are reconstructed in a cylindrical scintillating fiber calorimeter inside the magnet and a lead-glass array downstream. Charged particle identification is achieved by measuring energy loss in the wire chambers and using the flight time of particles between the target and detectors outside the magnet. The signals from all detectors are recorded with flash ADCs and/or pipeline TDCs into memories allowing trigger decisions with a latency of 3.3 μs. The detector operates routinely at trigger rates of 40 kHz and data rates of 600 megabytes per second. We describe the photon beam, the GlueX detector components, electronics, data-acquisition and monitoring systems, and the performance of the experiment during the first three years of operation.
Walk a Mile in the Leadership’s Shoes Mells, Anthony J., BS; Padela, Muhammad T., MD, MSc; Sleiman, Bilal, BS ...
The Orthopedic clinics of North America,
October 2018, Volume:
49, Issue:
4
Journal Article
Peer reviewed
Quality Improvement (QI) throughout health care in the United States continues to be of growing importance to both patients and providers. Leaders in health care including physicians, nurses, ...hospital administrators, and payors are all responsible for ensuring the continuation and growth of QI initiatives. This article will discuss various ways that healthcare leaders, with specific regard to orthopedic surgery, have utilized QI measures to provide better, more efficient, care to patients.
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