Preoperative Behavioral Health, Opioid, and Antidepressant Utilization and 2-year Costs After Spinal Fusion-Revelations From Cluster Analysis.
脊柱融合术后术前行为健康、阿片类药物和抗抑郁药的使用和 2 年费用-来自聚类分析的启示。
- 作者列表："Lerner J","Ruppenkamp J","Etter K","Headd JJ","Bhattacharyya S","Menzie AM","Pracyk JB","McGuire KJ
STUDY DESIGN:Retrospective administrative claims database analysis. OBJECTIVE:Identify distinct presurgery health care resource utilization (HCRU) patterns among posterior lumbar spinal fusion patients and quantify their association with postsurgery costs. SUMMARY OF BACKGROUND DATA:Presurgical HCRU may be predictive of postsurgical economic outcomes and help health care providers to identify patients who may benefit from innovation in care pathways and/or surgical approach. METHODS:Privately insured patients who received one- to two-level posterior lumbar spinal fusion between 2007 and 2016 were identified from a claims database. Agglomerative hierarchical clustering (HC), an unsupervised machine learning technique, was used to cluster patients by presurgery HCRU across 90 resource categories. A generalized linear model was used to compare 2-year postoperative costs across clusters controlling for age, levels fused, spinal diagnosis, posterolateral/interbody approach, and Elixhauser Comorbidity Index. RESULTS:Among 18,770 patients, 56.1% were female, mean age was 51.3, 79.4% had one-level fusion, and 89.6% had inpatient surgery. Three patient clusters were identified: Clust1 (n = 13,987 [74.5%]), Clust2 (n = 4270 [22.7%]), Clust3 (n = 513 [2.7%]). The largest between-cluster differences were found in mean days supplied for antidepressants (Clust1: 97.1 days, Clust2: 175.2 days, Clust3: 287.1 days), opioids (Clust1: 76.7 days, Clust2: 166.9 days, Clust3: 129.7 days), and anticonvulsants (Clust1: 35.1 days, Clust2: 67.8 days, Clust3: 98.7 days). For mean medical visits, the largest between-cluster differences were for behavioral health (Clust1: 0.14, Clust2: 0.88, Clust3: 16.3) and nonthoracolumbar office visits (Clust1: 7.8, Clust2: 13.4, Clust3: 13.8). Mean (95% confidence interval) adjusted 2-year all-cause postoperative costs were lower for Clust1 ($34,048 [$33,265-$34,84]) versus both Clust2 ($52,505 [$50,306-$54,800]) and Clust3 ($48,452 [$43,007-$54,790]), P < 0.0001. CONCLUSION:Distinct presurgery HCRU clusters were characterized by greater utilization of antidepressants, opioids, and behavioral health services and these clusters were associated with significantly higher 2-year postsurgical costs. LEVEL OF EVIDENCE:3.
研究设计: 追溯行政索赔数据库分析。 目的: 在腰椎后路融合术患者中确定不同的术前医疗保健资源利用 (HCRU) 模式，并量化其与术后费用的关系。 背景数据摘要: 术前HCRU可能预测术后经济结局，帮助医疗保健提供者识别可能受益于护理路径和/或手术方法创新的患者。 方法: 从索赔数据库中确定 2007 年至 2016 年期间接受一至两级腰椎后路融合术的私人保险患者。凝聚分层聚类 (HC) 是一种无监督的机器学习技术，通过术前HCRU跨 90 个资源类别对患者进行聚类。使用广义线性模型比较控制年龄、融合水平、脊柱诊断、后外侧/椎间入路和Elixhauser合并症指数的 2 年术后费用。 结果: 18,770 例患者中，56.1% 为女性，平均年龄 51.3，79.4% 为一级融合，89.6% 为住院手术。确定了 3 个患者簇: Clust1 (n = 13,987 [74.5%]) 、Clust2 (n = 4270 [22.7%]) 、Clust3 (n = 513 [2.7%])。最大的簇间差异见于抗抑郁药的平均供应天数 (Clust1: 97.1 天，Clust2: 175.2 天，Clust3: 287.1 天)，阿片类药物 (Clust1: 76.7 天，Clust2: 166.9 天，Clust3: 129.7 天)，和抗惊厥药 (Clust1: 35.1 天，Clust2: 67.8 天，Clust3:98.7 天)。对于平均医疗访视，集群间差异最大的是行为健康 (Clust1: 0.14，Clust2: 0.88，Clust3: 16.3) 和非胸腰椎办公室访视 (Clust1: 7.8，Clust2: 13.4，Clust3: 13.8)。Clust1 的平均 (95% 置信区间) 调整后 2 年全因术后费用较低 ($34,048 [$33，2 65-$34，84]) 与两个Clust 2 ($5 2，《法规的判例法》判例 505 [$50,306-$54,800]) 和Clust3 ($48，45 2 [$43,007-$54,790])，P < 0.0001. 结论: 不同的术前HCRU集群的特点是抗抑郁药、阿片类药物和行为健康服务的使用较多，这些集群与显著较高的 2 年术后费用相关。 证据级别: 3.
METHODS:BACKGROUND:Postoperative cognitive dysfunction (POCD) is a common complication after orthopedic surgery, which is not conducive to the prognosis of the elderly. AIMS:We performed this study to investigate the effects of oxycodone applied for patient-controlled intravenous analgesia (PCIA) on postoperative cognitive function in elderly patients after total hip arthroplasty (THA). METHODS:Ninety-nine participants were enrolled and allocated into two groups: oxycodone group (group O) and sufentanil group (group S). The primary outcome was the incidence of POCD, diagnosed according to the changes in the Mini-mental status examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores. The secondary outcomes included the plasma levels of S-100B protein and neuron-specific enolase (NSE), the amount of postoperative analgesic consumption and the incidence of adverse reactions. RESULTS:The incidence of POCD was significantly lower in patients receiving oxycodone up to the 3rd postoperative day (POD, 1st POD 27.3% vs. 51.1%, P = 0.021; 3rd POD 20.5% vs. 40.0%, P = 0.045), as compared to patients receiving sufentanil. The MMSE and MoCA scores of both groups decreased to varying degrees. However, compared with group S, the MMSE scores at 1st POD, 3rd POD, 5th POD and 7st POD in group O were higher than that in group S, while MoCA scores at 1st POD, 3rd POD and 5th POD in group O were higher. Compared with group S, the plasma levels of S-100B protein in group O at 4 h, 8 h, 12 h post-surgery were lower. While the plasma levels of NSE in group O at 4 h, 8 h, 12 h, 24 h post-surgery were lower. Number of PCIA boluses and consumption of analgesic drug during the first two POD were similar between two groups. However, postoperative incidence of nausea, vomiting and pruritus was significantly lower in patients receiving oxycodone. CONCLUSION:Oxycodone applied for PCIA in elderly patients after THA could reduce the incidence of POCD, improve postoperative cognitive function and decrease the adverse reactions.
METHODS:BACKGROUND:Primary treatment for Blount disease has changed in the last decade from osteotomies or staples to tension band plate (TBP)-guided hemiepiphysiodesis. However, implant-related issues have been frequently reported with Blount cases. The purpose of our study is to evaluate the surgical failure rates of TBP in Blount disease and characterize predictors for failure. METHODS:We performed an Institutional Review Board-approved retrospective chart-review of pediatric patients with Blount disease to evaluate the results of TBP from 2008 to 2017 and a systematic literature review. Blount cases defined as pathologic tibia-vara with HKA (hip-knee-ankle) axis and MDA (metaphyseal-diaphyseal angle) deviations ≥11 degrees were included in the analysis. Surgical failure was categorized as mechanical and functional failure. We studied both patient and implant-related characteristics and compared our results with a systematic review. RESULTS:In 61 limbs of 40 patients with mean follow-up of 38 months, we found 41% (25/61) overall surgical failure rate and 11% (7/61) mechanical failure rate corresponding to 11% to 100% (range) and 0% to 50% (range) in 8 other studies. Statistical comparison between our surgical failure and nonfailure groups showed significant differences in deformity (P=0.001), plate material (P=0.042), and obesity (P=0.044) in univariate analysis. The odds of surgical failure increased by 1.2 times with severe deformity and 5.9 times with titanium TBP in the multivariate analysis after individual risk-factor adjustment. All 7 mechanical failures involved breakage of cannulated screws on the metaphyseal side. CONCLUSIONS:Most of the studies have reported high failure rates of TBP in Blount cases. Besides patient-related risk factors like obesity and deformity, titanium TBP seems to be an independent risk factor for failure. Solid screws were protective for mechanical failure, but not for functional failure. In conclusion, efficacy of TBP still needs to be proven in Blount disease and implant design may warrant reassessment. LEVEL OF EVIDENCE:Level III-retrospective comparative study with a systematic review.
METHODS:INTRODUCTION:As cancer treatments continue to improve the overall survival rates, more patients with a history of cancer will present for anatomic total shoulder arthroplasty (TSA). Therefore, it is essential for orthopaedic surgeons to understand the differences in care required by this growing subpopulation. Although the current research suggests that good outcomes can be predicted when appropriately optimized patients with cancer undergo lower extremity total joint arthroplasty, similar studies for TSA are lacking. The primary study question was to examine whether a history of cancer was associated with an increased rate of venous thromboembolism (VTE) after TSA. Secondarily, we sought to examine any association between a history of prostate and breast cancer and surgical or medical complications after TSA. METHODS:Using a national insurance database, male patients with a history of prostate cancer and female patients with a history of breast cancer undergoing anatomic TSA for primary osteoarthritis were identified and compared with control subjects matched 3:1 based on age, sex, diabetes mellitus, and tobacco use. Patients with a history of VTE and patients who underwent reverse TSA or hemiarthroplasty were excluded. RESULTS:Female patients with a history of breast cancer and male patients with a history of prostate cancer undergoing TSA had significantly higher incidences of acute VTE (including deep venous thrombosis and pulmonary embolism) compared with matched control subjects (female patients: odds ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P = 0.024 and male patients: odds ratio, 1.37; 95% confidence interval, 1.05 to 1.79; P = 0.023). No significant differences were noted in the incidences of any other complications assessed. CONCLUSION:Although a personal history of these malignancies does represent a statistically significant risk factor for acute VTE after anatomic TSA, the overall VTE rate remains modest and acceptable. The rates of other surgical and medical complications are not significantly increased in patients with a history of these cancers after TSA compared with control subjects.