Non-compliance with clinical guidelines increases the risk of complications after primary total hip and knee joint replacement surgery

Background Total hip and total knee replacement (THR/TKR) are common and effective surgeries to reduce the pain and disability associated with arthritis but are associated with small but significant risks of preventable complications such as surgical site infection (SSI) and venous-thrombo-embolism (VTE). This study aims to determine the degree to which hospital care was compliant with clinical guidelines for the prevention of SSI and VTE after THR/TKR; and whether non-compliant prophylaxis is associated with increased risk of complications. Methods and findings A prospective multi-centre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKR/THR at one of 19 high-volume Australian public or private hospitals. Data were collected prior to surgery and for one-year post-surgery. Four adjusted logistic regression analyses were undertaken to explore associations between binary non-compliance and the risk of surgical complications: (1) composite (simultaneous) non-compliance with both (VTE and antibiotic) guidelines and composite complications [all-cause mortality, VTE, readmission/reoperation for joint-related reasons (one-year) and non-joint-related reasons (35-days)], (2) VTE non-compliance and VTE outcomes, (3) antibiotic non-compliance and any SSI, and (4) antibiotic non-compliance and deep SSI. Data were analysed for 1875 participants. Guideline non-compliance rates were high: 65% (VTE), 87% (antibiotics) and 95% (composite guideline). Composite non-compliance was not associated with composite complication (12.8% vs 8.3%, adjusted odds ratio [AOR] = 1.41, 95%CI 0.68–3.45, p = 0.40). Non-compliance with VTE guidelines was associated with VTE outcomes (5% vs 2.4%, AOR = 2.83, 95%CI 1.59–5.28,p < 0.001). Non-compliance with antibiotic guidelines was associated with any SSI (14.8% vs 6.1%, AOR = 1.98, 95%CI 1.17–3.62,p = 0.02) but not deep infection (3.7% vs 1.2%,AOR = 2.39, 95%CI 0.85–10.00, p = 0.15). Conclusions We found high rates of clinical variation and statistically significant associations between non-compliance with VTE and antibiotic guidelines and increased risk of VTE and SSI, respectively. Complications after THR/TKR surgery may be decreased by improving compliance with clinical guidelines

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty : an observational study

Background: Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery. Methods: This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs. Results: The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = − 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = − 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = − 0.02 SE = 0.008, p = 0.011) and 365-days (β = − 0.03, SE = 0.008, p = 0.002). The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = − 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = − 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = − 0.06, SE = 0.41, p = 0.880 EQ-5D: β = − 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect. Conclusions: Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days

Developing and evaluating an assessment to measure the impact and outcome after acquired brain injury

Acquired brain injury can have devastating effects on the person’s ability to participate in the activities and lifestyle of their choice. “I want my life back” is a frequently desired goal after brain injury. Rehabilitation aims to reduce the impact of ensuing impairments and facilitate the person’s return to meaningful activities and roles. Rehabilitation assumes to target those activities relevant to each person that “make life worth living” (1994, p.363). This study describes the development of an assessment instrument to measure the concept of ‘my life’. This has been defined as a person’s lifestyle: the typical way a person lives as expressed by their choice and participation in a wide variety of activities to meet needs in the context of their life (Merriam-Webster Dictionary, 2010; World Health Organisation [WHO], 1946). There is no consensus regarding which assessment might best address the concept of lifestyle after brain injury (Tate, 2010; Unsworth, 2000). The aim of this research was to complete the initial stages of the development of such an assessment. The research was carried out in three stages. Stage 1 of the study focussed on construction of the Lifestyle Assessment, a 72 item criterion referenced measure which acknowledges people are experts in their own life. The International Classification of Functioning, Disability and Health was selected as an appropriate basis for generating the initial items for the new instrument as it was thought to capture the “lived experience” of individuals after brain injury and provided a ready source of relevant items (Cicerone, 2004; Greenwood, 1999; WHO, 2001, p.229). In Stage 2 a qualitative review of the first version of the Lifestyle Assessment by a small number of people with brain impairment and clinicians provided an insider’s view of the utility of the new instrument. These processes informed refinement of the items, rating scale, format and administration of the assessment. The views of both groups were accommodated at this stage of the study. In Stage 3, the Lifestyle Assessment was piloted with 71 people with acquired brain injury. Rasch analysis was used to evaluate the degree to which the assessment was objective, precise and appropriate to measure lifestyle and for people with brain injury. The initial analysis indicated the need for adjustments to the rating scale. After refinement, the data were reanalysed using a modified collapsed rating scale. This stage of the study provided initial evidence of the reliability and validity of this instrument and identified several issues requiring further exploration. People were able to identify which activities were relevant to their life, and these ranged in number and difficulty. Participation in a chosen lifestyle is a complex phenomenon and appeared to be influenced by each person’s capacity, as well as supportive social environments, internal motivation and talent. People with co-morbid diagnoses had additional influences on their participation and this was found to be different than those with brain injury alone. The findings of the study were supported by literature on the nature of participation after brain injury. The Lifestyle Assessment offers a person centred assessment that focuses on Lifestyle. It reflects the ideas that individuals are unique and are able to make their own choices about which activities are important to them. It is a collaborative instrument that accommodates the needs of people with brain injury and clinicians who will use it, and displays elements considered essential to effective assessments. With further development this criterion referenced instrument has potential to make contributions to understanding and measuring the change that occurs in people’s life after brain injury

Clinical practice guideline compliance in orthopaedic surgery

Primary total hip arthroplasty (THA) & total knee arthroplasty (TKA) are common, cost-effective surgeries that reduce the pain and disability caused by osteoarthritis. THA/TKA are associated with a small risk of complications, such as venous thromboembolism (VTE) and surgical site infection (SSI), resulting in poorer outcomes. VTE & SSI prophylaxis clinical practice guidelines exist, but it is unclear whether service providers comply, or whether this affects outcomes. Methods A prospective multi-centre cohort study was undertaken in consenting adults with OA having primary TKA/THA at one of 19 high-volume Australian public/private hospitals. Data were collected before and for one-year post-surgery. Compliance was calculated with the National Health & Medical Research Council (NHMRC) & Australian Orthopaedic Association (AOA) VTE clinical guidelines & Therapeutic Guidelines (TG) Antibiotic. Logistic and linear regression were undertaken to explore associations between clinical guideline non-compliance and complications and patient-reported outcomes (Oxford Hip/Knee Scores [OH/KS], EQ-5D), and cephalosporin prophylaxis and SSI. Results Data were analysed for 1875 participants. Clinical guideline non-compliance rates averaged 87% for TG Antibiotic, 65% for NHMRC VTE clinical guideline & 20.1% for AOA VTE clinical guideline. NHMRC VTE clinical guideline noncompliance was associated with an increased VTE risk (adjusted odds ratio [AOR]=2.83, 95%CI=1.59-5.28, p< 0.001) and with lower (worse) 1-year EQ-5D Index scores (β=-0.03, SE=0.008,p=0.002) & an inconsequential reduction in OH/KS (β=-0.76,SE=0.30,p=0.01). AOA VTE clinical guideline non-compliance reduced the risk of symptomatic 90-day VTE (AOR=0.1, 95%CI=0.0-0.4,p=0.01). TG Antibiotic noncompliance was associated with higher SSI risk (AOR=1.98, 95%CI=1.17-3.62,p=0.02) but not with PROMs. Reduced SSI risk was associated with cephalosporin dose (any SSI; AOR=0.68, 95%CI=0.47–0.99, p=0.05) and commencing antibiotics before skin incision (0-60 mins: any SSI, AOR=0.56,95%CI=0.36–0.89,p=0.01; DSSI, AOR=0.56,95%CI=0.36–0.89,p=0.01; ≥60 minutes: AOR=0.35, 95%CI=0.17-0.70,p=0.004; DSSI, AOR=0.35,95%CI=0.17-0.70,p=0.004). Changing dose (AOR=1.76, 95%CI=1.22–2.57,p=0.02) & receiving preoperative non-cephalosporin (AOR=1.35, 95%CI=1.01–1.81,p=0.04) increased SSI risk. Antibiotic prophylaxis duration was not associated with SSI. Summary Non-compliance with NHMRC VTE clinical guidelines & TG Antibiotic increased the risk of VTE & SSI. The contrary NHMRC & AOA VTE clinical guideline findings may be explained by AOA recommending aspirin. Increased compliance with high-quality VTE & antibiotic clinical guidelines may improve THA/TKA outcomes

Validity of patient-reported complications after total hip and knee arthroplasty

Background: Evaluating the effectiveness of total hip arthroplasty (THA) and total knee arthroplasty (TKA) often relies on accurate patient reporting of postoperative complications. Despite this, there is little research regarding the accuracy of patient reports. We aimed to determine the accuracy of patient-reported significant complications after THA and TKA. Methods: Patients were recruited prior to undergoing primary hip or knee arthroplasty at 19 high-volume hospitals. After surgery, follow-up of patients via telephone interviews at 35, 90 and 365 days recorded surgical outcomes including readmission, reoperation and venous thromboembolism (VTE). Patient-reported complications were verified via medical record audits and liaison with surgeons, general practitioners or other health professionals. Surgical and demographic information and patient-reported and verified complications were entered into a database. Patient-reported and verified complications were compared for readmission, reoperation and VTE. Results: The sample included 150 of 1811 patients who reported a total of 242 significant complications. Of the 242 patient-reported complications, 224 (92.6%) were correct (true positive). The type of complication had variable levels of accuracy in patient reports. Readmission to hospital was accurately reported by 90.2% (129/143) of patients. Reoperation (including any manipulations under anaesthesia, joint washouts, reductions of dislocated joints and revisions) was accurately reported by 98.7% (75/76) of patients. VTE was accurately reported by 86.7% (20/23) of patients. Conclusion: A high level of accuracy in patient-reported experience of complications was demonstrated following THA and TKA. Patient-reported complications may be reliably used for post-operative surveillance of joint replacement surgery

Paediatric intubation in Australasian emergency departments : A report from the ANZEDAR

Objectives To describe the epidemiology, clinical practice and outcomes of paediatric ED intubation in Australia and New Zealand. Method Prospectively collected airway management audit data from 43 EDs in Australia and New Zealand that was submitted to the Australia and New Zealand Emergency Department Airway Registry between 2010 and 2015. Results Paediatric cases accounted for 4.94% (270/5463) of cases (median age = 3, interquartile range [IQR] = 2–9). A median of 5 (IQR = 2–9) intubations were reported per department per year. Most intubations were performed for medical indications (72.2%), including seizure (25.2%) and respiratory failure (15.2%). Patients were physiologically compromised prior to intubation with 69.5% comatose, 50.9% outside of the normal age-adjusted range for respiratory rate, 15.9% hypoxic and 12.6% hypotensive. Complication rate was 33.3% and desaturation was the most common (18.5%). The ED mortality rate was 3.8%. First pass success (FPS) was 80% (95% CI 75.2–84.8). Infants less than 1 year of age had lower FPS, higher rates of difficult laryngoscopy and higher rates of desaturation than other age groups. Conclusion Paediatric intubation in Australasian EDs is rare from a departmental and individual provider viewpoint. Success rates are similar to contemporary international registries. Complications are common and ongoing collaborative multicentre audit with resultant quality improvement is desirable to facilitate improved success and reduced complications

Association between pre-operative anxiety and/or depression and outcomes following total hip or knee arthroplasty

Purpose: While elective primary total hip (THA) and knee (TKA) arthroplasty are effective procedures for addressing the symptoms associated with advanced osteoarthritis, there is evidence to suggest that patient anxiety and depression are linked to poorer outcomes following surgery. Methods: A secondary analysis of prospectively-collected data of people undergoing primary elective THA or TKA for osteoarthritis across 19 hospitals was performed. We assessed outcomes at 1 year post-surgery for people with and without medically treated anxiety and/or depression at the time of surgery (A/D and no-A/D). We used unadjusted and adjusted analyses to compare improvement in Oxford Hip or Knee Scores, the incidences of major post-operative complications, satisfaction and index joint improvement by A/D status. Results: 15.2% (254/1669) of patients were identified with anxiety and/or depression at time of surgery. In the unadjusted analysis, the A/D group had greater mean Oxford score improvement by 2.1 points (95% CI 0.8 to 3.4, p = 0.001), increased major complications (OR 1.39, 95% CI 1.05 to 1.85, p = 0.02), were less likely to report a “much better” global improvement for index joint (OR 0.56, 95% CI 0.38 to 0.83, p = 0.003), and there was no statistically significant difference in the rate of satisfaction with the results of surgery (OR 0.64, 95% CI 0.37 to 1.10, p = 0.10). The adjusted analysis found no significant associations between A/D vs. no-A/D and any of the reported outcomes. Conclusion: After adjustment for confounding variables, people with anxiety and/or depression pre-operatively, compared to those without, have similar outcomes following hip or knee arthroplasty

Patient satisfaction and perception of success after total knee arthroplasty are more strongly associated with patient factors and complications than surgical or anaesthetic factors

Purpose A proportion of TKA recipients following TKA are dissatisfied with their outcome. Our hypothesis is that patient satisfaction with TKA and perception of success of surgery are associated with patient comorbidities and overall health status, surgical and anaesthetic techniques as well as processes of post-operative care after TKA. The aims were to (i) measure the incidence of patient unfavourable outcomes—defined as dissatisfaction with the surgery or lack of joint-specific global improvement—1 year after TKA, and to explore the differences between these two outcomes of interest; (ii) assess the relationship between the development of these unfavourable outcomes and patient-reported knee function and overall quality of life; (iii) explore the associations between pre- and peri-operative variables and the development of these unfavourable outcomes 1 year after TKA. Methods This study includes analysis of data from a prospective cohort of 1017 TKA recipients. Pre-operative patient variables, surgical and acute-care data were collected. The Oxford knee score and the global perception of improvement were used to assess satisfaction and success 365 days post-surgery. Results From 1017 patients (56% female), mean age 68 years and BMI 32, 68 pts (7%) were dissatisfied with the outcome of surgery, 141 pts (14%) believed surgery was unsuccessful 1 year after TKA. A negative outcome was noted in 151 (15%) patients for either satisfaction or success, and 58 (6%) of patients reported neither good satisfaction nor success after surgery. Dissatisfied patients reported worse mean OKS (26.4 [SD 8.03] vs 42.3 [SD 5.21], p  2 and not resurfacing the patella were factors associated with the development of dissatisfaction with TKA and with patient perceived unsuccessful results of TKA. Multivariable logistic regression of patient satisfaction and success of TKA showed that compensation cases (OR 26.91, p  2 (OR 1.83, p = 0.04 for dissatisfaction and OR 1.57, p = 0.03 for unsuccessful TKA)and the development of a complication after TKA (OR 3.4, p < 0.001 for dissatisfaction and OR 2.39, p < 0.001 for unsuccessful TKA) were associated with the development of a negative outcome in both groups. Patella preservation (OR 1.96, p = 0.03) was associated with dissatisfaction, whereas the use of cruciate retaining femoral prosthesis was associated with less successful results of TKA (OR 1.78, p = 0.009). Conclusions An unfavourable outcome occurs in approximately 7–15% of patients following TKA. The incidence varies with how an unfavourable result is defined and many factors are associated with this outcome though prosthetic design or patella resurfacing do not appear to be important