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Large Joints Feature

Courtesy of Andrew Huth © and Wikimedia Commons

Spine Surgery Not Driving Opioid Use; Managing Weekend TKA Patients; Remove Hip Fractures From Bundle!

Elizabeth Hofheinz, M.P.H., M.Ed. • Fri, August 18th, 2017

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Spine Surgery Not Driving Long-Term Prescription Opioid Use

A light is shining on physicians these days when it comes to the opioid epidemic. One new study excludes spine surgeons from the bulk of the problem, however.

The study, “Risk Factors for Prolonged Opioid Use Following Spine Surgery, and the Association with Surgical Intensity, Among Opioid-Naive Patients,” was published in the August 2, 2017 edition of the Journal of Bone and Joint Surgery.

Andrew Schoenfeld, M.D. is an orthopedic spine surgeon at Brigham and Women’s Hospital in Boston, Massachusetts, and was a co-author on the study. Dr. Schoenfeld told OTW, “In light of the opioid crisis, we thought it was important to investigate the extent to which spine surgical interventions were responsible for initiating a process that culminates in sustained opioid drug use.”

“The population under study is representative of the American demographic at greatest risk of developing sustained opioid drug use. The nature of the data allows us to accurately determine prescription opioid drug use before and after the surgical event.”

“By six months following discharge, nearly all patients had discontinued opioid use after spine surgery. As only 0.1% of the patients continued opioid use at six months following surgery, these results indicate that spine surgery among opioid-naive patients is not a major driver of long-term prescription opioid use.”

“Despite a low risk overall, socioeconomic status and pre-existing mental health disorders may be factors associated with sustained opioid use in patients following spine surgery. Additional resources may be devoted to individuals with these characteristics to minimize the potential for post-operative dependence.”

“There is of course a great deal of information in the popular media regarding the role that surgical intervention may play in contributing to the opioid epidemic. As we look for constructive ways to respond to this crisis, it does not appear that spine surgery is a major driver of sustained post-operative use among those patients who are not using these types of medications in the period leading up to the surgical procedure.”

Needed: Better Management of Weekend TKA Patients

What are the facts about weekend hospital stays and adverse outcomes?

This is what a team from Cleveland Clinic and SUNY Downstate Medical Center wanted to determine. Their work, “Is Day of Surgery Associated With Adverse Clinical and Economic Outcomes Following Primary Total Knee Arthroplasty?” appears in the August 2017 edition of The Journal of Arthroplasty.

Michael Mont, M.D., Chairman Orthopaedics at Cleveland Clinic Orthopaedic & Rheumatologic Institute in Ohio and co-author on the study, commented to OTW, “In my practice, I noticed that patients who are ready for discharge during the weekend sometimes stay in the hospital until Monday because of the shortage of appropriate staff to complete the discharge process.”

“I proceeded to call my colleagues from several orthopaedic centers across the country, who acknowledged that they are facing a similar problem in their hospitals. Therefore, I decided to analyze a large New York State database to see if this was a global issue in patients who undergo total knee arthroplasty (TKA).”

“The New York Statewide Planning and Research Cooperative System (SPARCS) is a comprehensive healthcare data reporting system established by the New York State Department of Health. This database collects data on all hospital admissions in New York State. One of the limitations of this and many other databases is the lack of long-term follow up. This limitation underscores the need to create and maintain Joint Replacement Registry in the United States.”

The authors wrote, “We identified 115,053 patients who underwent primary TKA on a weekday between 2009 and 2013 in New York State.”

Dr. Mont told OTW, “We found that patients who undergo primary total knee arthroplasty later in the week (Wednesday, Thursday, and Friday), have longer and more expansive hospital course. However, these patients did not have an increased risk of 90-day readmission.”

“This report underlines the need to better manage total knee arthroplasty patients during the weekend by providing sufficient staff for discharge processing. This will not only decrease the length of stay and hospital costs, but potentially increase patient’s satisfaction.”

“Because of the current healthcare shift from pay-for-service to pay-for-value model, all orthopaedic surgeons should strive to improve patient outcomes and satisfaction while attempting to decrease hospital costs. In this study, we identified one of the many issues that currently burden the healthcare system. I believe we, orthopaedic surgeons, should take an initiative in identifying and rectifying these shortcomings.”

Study: Remove Hip Fractures From Bundle!

In order to stop unfairly punishing hospitals, says a new study, the current bundled payment needs to reconsider hip fractures. “Hip Arthroplasty for Fracture vs Elective Care: One Bundle Does Not Fit All,” appears in the August 2017 edition of The Journal of Arthroplasty.

Richard S. Yoon, M.D., orthopedic trauma surgeon at the New York University Hospital for Joint Diseases and co-author on the study, commented to OTW, “The Bundled Payment Initiative set forth by CMS [Centers for Medicare & Medicaid Services] is here and growing. There's no way out of it other than refining it and maximizing value with cost in any way. We analyzed the fracture subset because we noted outliers that remained consistent through each quarter.”

“A lot of credit goes to the well kept data in the New York SPARCS [Statewide Planning and Research Cooperative System] database—with it we were able to analyze very specific, yet large numbers of data to help answer our questions. Obviously, this still is not as good as level 1 randomized controlled trials, but performed properly, has allowed for very important epidemiological level information that can help mold future health care decisions.”

“Our results indicate that fracture patients shouldn't be included in the bundle. They are different, largely sicker, patients than those who are scheduled for elective total hip arthroplasty. The risk for complication, readmission, death, ICU [intensive care unit] stay, all went up in the fracture cohort compared to the elective group.”

“We commend CMS for listening and for this past year, removing hip fracture patients from the bundle.”

“This is a great example of orthopaedic surgeons (not only our authors but to those who also performed similar studies) collecting data and collaborating that actually instills change. Let's continue to do more of the same.”

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