Trends and Regional Variation in Hip, Knee and Shoulder Replacement

Analyzes patterns in underuse or overuse of joint replacements among Medicare beneficiaries by geographic regions and race/ethnicity. Explores underlying factors and highlights the need for physician and patient education and shared decision making

Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation

Abstract Background A high quality decision requires that patients who meet clinical criteria for surgery are informed about the options (including non-surgical alternatives) and receive treatments that match their goals. The aim of this study was to evaluate the psychometric properties and clinical sensibility of a patient self report instrument, to measure the quality of decisions about total joint replacement for knee or hip osteoarthritis. Methods The performance of the Hip/Knee Osteoarthritis Decision Quality Instrument (HK-DQI) was evaluated in two samples: (1) a cross-sectional mail survey with 489 patients and 77 providers (study 1); and (2) a randomized controlled trial of a patient decision aid with 138 osteoarthritis patients considering total joint replacement (study 2). The HK-DQI results in two scores. Knowledge items are summed to create a total knowledge score, and a set of goals and concerns are used in a logistic regression model to develop a concordance score. The concordance score measures the proportion of patients whose treatment matched their goals. Hypotheses related to acceptability, feasibility, reliability and validity of the knowledge and concordance scores were examined. Results In study 1, the HK-DQI was completed by 382 patients (79%) and 45 providers (58%), and in study 2 by 127 patients (92%), with low rates of missing data. The DQI-knowledge score was reproducible (ICC = 0.81) and demonstrated discriminant validity (68% decision aid vs. 54% control, and 78% providers vs. 61% patients) and content validity. The concordance score demonstrated predictive validity, as patients whose treatments were concordant with their goals had more confidence and less regret with their decision compared to those who did not. Conclusions The HK-DQI is feasible and acceptable to patients. It can be used to assess whether patients with osteoarthritis are making informed decisions about surgery that are concordant with their goals

A thin mobile client for a groupware application

Until recently, desktop clients were sufficient platforms for running groupware. The dramatic increase in the use of mobile devices, user mobility and the growth of sophistication of device resources now requires the exploration of alternative clients running on devices such as PDAs and mobile phones. This paper describes our exploration of a BlackBerry thin client for an open source groupware application called the Collaborative Virtual Workspace (CVW). It outlines our development process and implementation and the challenges that we encountered, and outlines our plans for future work

Patient-Reported Outcomes After Revision of Metal-on-Metal Total Bearings in Total Hip Arthroplasty

BACKGROUND: Failure of metal-on-metal (MOM) total hip arthroplasty (THA) bearings is often accompanied by an aggressive local reaction associated with destruction of bone, muscle and other soft tissues around the hip. Little is known about whether patient-reported physical and mental function following revision THA in MOM patients are compromised by this soft tissue damage, and whether revision of MOM THA is comparable to revision of hard-on-soft bearings such as metal-on-polyethylene (MOP). METHODS: We identified 75 first-time MOM THA revisions and compared them to 104 first-time MOP revisions. Using prospective patient-reported measures via the Veterans RAND-12, we compared physical (PCS) and mental function (MCS) at pre-operative baseline and post-operative follow-up between revision MOM THA and revision MOP THA. RESULTS: PCS did not vary between the groups pre-operatively and at 1 month, 3 months, and 1 year post-operatively. MCS pre-operatively and 1 and 3 months post-operatively were lower in patients in the MOM cohort compared to patients with MOP revisions (Baseline 43.7 vs. 51.3, P<0.001; 1 month: 44.9 vs. 53.3, P<0.001; 3 months 46.0 vs. 52.3, P=0.016). However, by 1 year, MCS scores were not significantly different between the revision cohorts. CONCLUSION: Post-revision physical function in revised MOM THA patients does not differ significantly from the outcomes of revised MOP THA. Mental function is markedly lower in MOM patients at baseline and early in the post-operative period, but does not differ from MOP patients at 1 year after revision. This information should be useful to surgeons and physicians facing MOM THA revision

Improving shared decision making in osteoarthritis

The burden of chronic pain for those who have it and their families is substantial, says Henry McQuay (doi: 10.1136/bmj.39520.699190.94), and these patients deserve better. Dawn Stacey and colleagues describe an example of quality improvement in practice for one group of people with chronic pain, those with osteoarthriti

Cost-Effectiveness of Preoperative Nasal Mupirocin Treatment in Preventing Surgical Site Infection in Patients Undergoing Total Hip and Knee Arthroplasty: A Cost-Effectiveness Analysis

Objective.To perform a cost-effectiveness analysis to evaluate preoperative use of mupirocin in patients with total joint arthroplasty (TJA).Design.Simple decision tree model.Setting.Outpatient TJA clinical setting.Participants.Hypothetical cohort of patients with TJA.Interventions.A simple decision tree model compared 3 strategies in a hypothetical cohort of patients with TJA: (1) obtaining preoperative screening cultures for all patients, followed by administration of mupirocin to patients with cultures positive for Staphylococcus aureus; (2) providing empirical preoperative treatment with mupirocin for all patients without screening; and (3) providing no preoperative treatment or screening. We assessed the costs and benefits over a 1-year period. Data inputs were obtained from a literature review and from our institution's internal data. Utilities were measured in quality-adjusted life-years, and costs were measured in 2005 US dollars.Main Outcome Measure.Incremental cost-effectiveness ratio.Results.The treat-all and screen-and-treat strategies both had lower costs and greater benefits, compared with the no-treatment strategy. Sensitivity analysis revealed that this result is stable even if the cost of mupirocin was over $100 and the cost of SSI ranged between$26,000 and $250,000. Treating all patients remains the best strategy when the prevalence of S. aureus carriers and surgical site infection is varied across plausible values as well as when the prevalence of mupirocin-resistant strains is high.Conclusions.Empirical treatment with mupirocin ointment or use of a screen-and-treat strategy before TJA is performed is a simple, safe, and cost-effective intervention that can reduce the risk of SSI. S. aureus decolonization with nasal mupirocin for patients undergoing TJA should be considered.Level of Evidence.Level II, economic and decision analysis.Infect Control Hosp Epidemiol 2012;33(2):152-159</jats:sec

Preoperative body mass index and physical function are associated with length of stay and facility discharge after total knee arthroplasty

BackgroundHospital length of stay (LOS) and facility discharge are primary drivers of the cost of total knee arthroplasty (TKA). We sought to identify modifiable patient factors that were associated with increased LOS and facility discharge after TKA.MethodsProspective data were reviewed from 716 consecutive, primary TKA procedures performed by two arthroplasty surgeons between 2006 and 2012 at a single institution. Preoperative body mass index (BMI), Veterans RAND-12 (VR-12) physical component score (PCS), and hemoglobin level were collected in addition to other adjusters. Multivariate linear and logistic models were constructed to predict LOS and facility discharge, respectively.ResultsAfter adjustment, higher BMI was associated with increased LOS in a dose-response effect: Compared to normal weight (BMI &lt;25) overweight (25-29.9) was associated with longer LOS by 0.32days (P=0.038), class-I obesity (30-34.9) by 0.33days (P=0.024), class-II obesity (35-39.9) by 0.67days (P=0.012) and class-III obesity (&gt;40) by 1.15days (P&lt;0.001). Class-III obesity was associated with facility discharge (odds ratio=2.08, P=0.008). Poor PCS was associated with increasing LOS: compared to PCS≥50, PCS 20-29 was associated with a LOS increase of 0.40days (P=0.014) and PCS&lt;20 with a LOS increase of 0.64days (P=0.031).ConclusionPatient BMI has a dose-response effect in increasing LOS. Poor PCS was associated similarly with increased LOS. These associations for of BMI and PCS suggest that improvement preoperatively, by any amount, may potentially translate to decreased LOS and perhaps lower the cost associated with TKA