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Prednisone use is associated with higher rates of periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). However, the relationship between prednisone dosage and infection risk is ill-defined. Therefore, this study aimed to assess the relationship between prednisone dosage and rates of PJI following TJA.A national database was queried for all elective total hip (THA) and total knee arthroplasty (TKA) patients between 2015 and 2020. Patients who received oral prednisone following TJA were matched in a 1:2 ratio based on age and sex to patients who did not. Univariate and multivariate regression analyses were performed to assess the 90-day risk of infectious complications based on prednisone dosage: 0 to 5, 6 to 10, 11 to 20, 21 to 30, and30 milligrams. Overall, 1,322,043 patients underwent elective TJA (35.9% THA, 64.1% TKA). Of these, 14,585 (1.1%) received prednisone and were matched to 29,170 patients who did not.After controlling for confounders, TKA patients taking prednisone were at increased risk for sepsis (adjusted odds ratio [aOR] 2.76, p0.001), PJI (aOR 2.67, p0.001), and SSI (aOR: 2.56, p=0.035). THA patients taking prednisone were at increased risk for sepsis (aOR: 3.21, p0.001) and PJI (aOR: 1.73, p=0.001). No dose-dependent relationship between prednisone and infectious complications was identified when TJA was assessed in aggregate.Patients receiving prednisone following TJA were at increased risk of PJI and sepsis. A dose-dependent relationship between prednisone and infectious complications was not identified. Arthroplasty surgeons should be aware of these risks and counsel TJA patients who receive prednisone therapy.

STUDY DESIGN Retrospective review. OBJECTIVE The aim of this study was to understand the potential correlation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response time on reported satisfaction following spine surgery hospitalization. SUMMARY OF BACKGROUND DATA With increasing emphasis on patient satisfaction metrics, such as HCAHPS, hospital reputations, and reimbursements are being affected by the results of such surveys. HCAHPS is a 32-question survey about patient experience in the hospital and after discharge. METHODS HCAHPS surveys were routinely sent to all patients admitted after spine surgery at an academic medical center between January 2013 and August 2017. Survey data, survey return time, patient demographics, and 30-day postoperative outcomes were gathered for all spine surgery patients who returned the survey. Multivariate regression analysis controlling for age, sex, BMI, functional status, American Society of Anesthesiologists class, education, and race was used to determine whether there were differences in rates of "Top Box" response between different time ranges of survey return. RESULTS In total, 1495 consecutive spinal surgery patients who returned their HCAHPS survey were identified. Of these, 31.51% returned their surveys within 21 days, 48.09% returned them between 22 to 42 days, 13.58% returned them between 43 to 64 days, and 6.82% returned them ≥65 days after distribution. Multivariate regression demonstrated no statistical differences in reported satisfaction between surveys returned between days 0 to 21 and days 22 to 42. However, there were significantly lower scores reported by surveys returned on days 43 to 64 and 65 plus days. CONCLUSION Centers for Medicare and Medicaid Services only considers HCAHPS surveys returned within the first 42 days. It appears that the survey responses are similar over this time period. Beyond this time, lower scores are reported. Further attention to this less satisfied, later HCAHPS survey returning group seems warranted.Level of Evidence: 2.

Obesity and diabetes have independently been shown to predispose to adverse outcomes after total hip arthroplasty (THA). These may have a coupled effect on perioperative risks. The purpose of this study was to evaluate the effect of body mass index (BMI) on adverse outcomes in nondiabetic (ND), non-insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) patients.Patients undergoing primary THA were selected from the National Surgical Quality Improvement Program Database from 2012 to 2016 and categorized as ND, NIDDM, and IDDM. BMI, demographics, and 30-day perioperative outcomes were assessed for each group. Multivariate logistic regressions controlling for demographics, functional status, and American Society of Anesthesiologists were used to determine the odds ratio of serious adverse event (SAE) in each diabetes group for patients with BMI ≥ 40 kg/m compared with a control group of ND patients with a normal BMI (18.5 to 24.9 kg/m).A total of 108,177 patients were included. The results demonstrate that ND (odds ratio 1.65; P0.001) and NIDDM (odds ratio 1.75; P = 0.007) patients have similar risks of SAE, whereas IDDM (odds ratio 2.79; P0.001) patients have a greater risk of adverse events, particularly at BMIs greater than 40 kg/m.Consistent with previous reports, ND (odds ratio 1.65; P0.001) and NIDDM (odds ratio 1.75; P = 0.007) morbidly obese patients (BMI40 kg/m) had an increased odds of SAEs after THA, but for IDDM (odds ratio 2.79; P0.001) patients this increased odds was notably higher. Although patients with IDDM have increased rates of adverse events compared with ND and NIDDM patients, these findings should not be used to establish strict BMI cutoffs in patients with IDDM. Nonetheless, the results suggest additional factors, such as patient medical history and diabetes control, should be considered when evaluating patients with IDDM for THA.Level III.

Hip osteoarthritis (OA) can be idiopathic or develop secondary to structural joint abnormalities of the hip joint (alteration of normal anatomy) and/or due to a systemic condition with joint involvement. Early osteoarthritic changes to the hip can be completely asymptomatic or may cause the development hip symptomatology without evidence of OA on radiographs. Delaying the progression of hip OA is critical due to the significant impact of this condition on the patient's quality of life. Pre-OA of the hip is a newly established term that is often described as the development of signs and symptoms of degenerative hip disease but no radiographic evidence of OA. Advanced imaging methods can help to diagnose pre-OA of the hip in patients with hip pain and normal radiographs or aid in the surveillance of asymptomatic patients with an underlying hip diagnosis that is known to increase the risk of early OA of the hip. These methods include the delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC), quantitative magnetic resonance imaging (qMRI- T1rho, T2, and T2* relaxation time mapping), 7-Tesla MRI, computed tomography (CT), and optical coherence tomography (OCT). dGEMRIC proved to be a reliable and accurate modality though it is limited by the significant time necessary for contrast washout between scans. This disadvantage is potentially overcome by T2 weighted MRIs, which do not require contrast. 7-Tesla MRI is a promising development for enhanced imaging resolution compared to 1.5 and 3T MRIs. This technique does require additional optimization and development prior to widespread clinical use. The purpose of this review was to summarize the results of translational and clinical studies investigating the utilization of the above-mentioned imaging modalities to diagnose hip pre-OA, with special focus on recent research evaluating their implementation into clinical practice.

With the increasing medical complexity of patients undergoing posterior lumbar surgery, more patients are pharmacologically immunosuppressed to manage chronic conditions. The effects of immunosuppression have become of greater interest across multiple surgical specialties. The goal of the current study was to investigate whether long-term corticosteroid use is independently associated with perioperative adverse outcomes among patients undergoing posterior lumbar surgery. Patients who underwent elective posterior lumbar spine surgery (decompression and/or fusion) were identified in the 2005–2016 National Surgical Quality Improvement Program (NSQIP) database. Patient factors, surgical factors, and 30-day perioperative outcomes for patients taking long-term corticosteroids were compared with those for patients who were not taking these drugs. Propensity matching and multivariate analysis were used to evaluate comparable patients while controlling for potentially confounding variables. In total, 140,519 patients undergoing posterior lumbar spine surgery were identified. Of these, 5243 (3.73%) were taking corticosteroids. After propensity matching and controlling for age, sex, body mass index, functional status, American Society of Anesthesiologists class, and surgical procedure, those taking corticosteroids were at greater risk for any adverse event (odds ratio, 1.45), a serious adverse event (odds ratio, 1.57), a minor adverse event (odds ratio, 1.47), infection (odds ratio, 1.48), reoperation (odds ratio, 1.48), and readmission (odds ratio, 1.47) ( P ≤.001 for each). The findings confirmed that long-term corticosteroid use is associated with significant increases in perioperative adverse outcomes for patients undergoing elective posterior lumbar surgery, even with matching and controlling for potentially confounding variables. These findings can guide patient counseling and preemptive interventions before surgery for this patient population. [ Orthopedics . 2021;44(3):172–179.]

Prior Authorization (PA) is an insurance policy that requires providers to obtain permission before delivery of certain medical services. The aim is to ensure appropriate utilization of health care on the basis of clinical guidelines and to minimize costly procedures. The overall impact of PAs has not been well studied; however, many arguments exist in support and opposition to this practice. The Prior Authorization Transparency Act and the Healthcare Transparency Initiative are legislations enacted by the state of Arkansas to study and mitigate the effects of PAs. These legislations are particularly relevant to orthopedic surgery, as many orthopedic procedures and services require PA. There is limited evidence regarding the effects of PAs on the field of orthopedics. Studying these effects is critical to ensuring high-quality care for patients and reducing administrative and provider burden associated with PAs.

BACKGROUND: Rising healthcare costs have led to increased focus on the need to achieve a higher “value of care.” As value-maximization efforts expand to include more complex surgical patients, evidence to support meaningful implementation of complication-based initiatives is lacking. The objective of this study was to compare incremental costs of complications following major gastrointestinal (GI) resections for organ-specific malignant neoplasia using nationally-representative data. METHODS: National (Nationwide) Inpatient Sample data, 2001-2014, were queried for adult (≥18y) patients undergoing major resections for malignant neoplasia. Based on system-based complications considered relevant to the long-term treatment of GI disease, stratified differences in risk-adjusted incremental hospital costs and complication probabilities were compared. Differences in surgical outcomes and costs over time were also assessed. RESULTS: A total of 293,967 patients were included, weighted to represent 1,408,117 patients nationwide. One-fourth (26.1%, 95%CI: 25.7-26.4%) experienced ≥1 pre-discharge complication (range: 45.3% esophagectomy to 24.0% rectal resection). Resultant annual risk-adjusted incremental hospital costs totaled $540 million nationwide (19.5% of the overall cost of care and an average of $20,900 per-patient). Costs varied substantially with both cancer/resection type and complication group, ranging from $76.7 million for colectomies with infectious complications to $0.2 million for rectal resections with urinary complications. For each resection type, infectious ($154.7 million), GI ($85.5 million), and pulmonary ($77.9 million) complications were among the most significant drivers of increased hospital cost. CONCLUSIONS: Quantifying and comparing the impact of complications on an indication-specific level in more complex patients offers an important step toward allowing providers/payers to meaningfully prioritize the design of novel and adaptation of existing value-maximization approaches.

Quality metrics are the methods by which hospitals and insurers measure the quality of care at a particular institution or practice. Examples of quality metrics include structural measures, process measures, objectively assessed outcome measures, registries, patient-reported outcome measures, and patient-reported satisfaction through the hospital consumer assessment of healthcare providers and systems. Each metric provides unique insight about the care a particular institution can provide. These metrics are particularly relevant in spine care with spinal issues being such a common reason for patients to seek medical attention and mixed surgical outcomes for different surgical indications. The results are useful to patients choosing the institution at which they receive treatment, to hospitals in guiding efforts to improve their quality of care, and to insurers to rate hospitals and providers to direct policies and reimbursements. These metrics are continually evolving in order to adapt to constantly changing healthcare systems. No single metric is perfect, while each have their own unique benefits and insights about an institution; they also come with some potential downsides that must be balanced by using a varied set of measures.