Mitigation and Education

Aggarwal, Vinay K.; Tischler, Eric H.; Lautenbach, Charles; Williams, Gerald R.; Abboud, Joseph A.; Altena, Mark; Bradbury, Thomas L.; Calhoun, Jason H.; Dennis, Douglas A.; Gaizo, Daniel J. Del; Font-Vizcarra, Lluís; Huotari, Kaisa; Kates, Stephen L.; Koo, Kyung Hoi; Mabry, Tad M.; Moucha, Calin S.; Palacio, Julio César; Peel, Trisha; Poolman, Rudolf W.; Robb, William J.; Salvagno, Ralph; Seyler, Thorsten M.; Skaliczki, Gábor; Vasarhelyi, Edward M.; Watters, William C.

doi:10.1016/j.arth.2013.09.028

Cited by 45 publications

(24 citation statements)

References 100 publications

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“…In addition, both often are considered modifiable risk factors, and some surgeons suggest that they should be corrected before elective TKA [1,12]. However, morbid obesity may be less modifiable than malnutrition.…”

Section: Discussionmentioning

confidence: 99%

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Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA

Nelson

Elkassabany

Kamath

et al. 2015

Clin Orthop Relat Res

129

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Background Morbid obesity and malnutrition are thought to be associated with more frequent perioperative complications after TKA. However, morbid obesity and malnutrition often are co-occurring conditions. Therefore it is important to understand whether morbid obesity, malnutrition, or both are independently associated with more frequent perioperative complications. In addition, assessing the magnitude of an increase in complications and whether these complications are major or minor is important for both conditions. Questions/purposes We asked: (1) Is morbid obesity independently associated with more frequent major perioperative complications after TKA? (2) Are major perioperative complications after TKA more prevalent among patients with a low serum albumin? Methods The National Surgical Quality Improvement Program (NSQIP) database was analyzed from 2006 to 2013. Patients were grouped as morbidly obese (BMI C 40 kg/m 2 ) or nonmorbidly obese (BMI C 18.5 kg/m 2 to \ 40 kg/m 2 ), or by low serum albumin (serum albumin level \ 3.5 mg/dL) or normal serum albumin (serum albumin level C 3.5 mg/dL). The study cohort included 77,785 patients, including 35,573 patients with a serum albumin level of 3.5 g/dL or greater and 1570 patients with a serum albumin level less than 3.5 g/dL. Therefore, serum albumin levels were available for only 37,173 of the 77,785 of the patients (48%). There were 66,382 patients with a BMI between 18.5 kg/m 2 and 40 kg/m 2 and 11,403 patients with a BMI greater than 40 kg/m 2 . Data were recorded on patient mortality along with 21 complications reported in the NSQIP. We also developed three composite complication variables to represent risk of any infections, cardiac or pulmonary complications, and any major complications. For each complication, multivariate logistic regression analysis was performed. Independent variables included patient age, sex, race, BMI, American Society of Anesthesiologists classification, year of surgery, and Charlson comorbidity index score. Results Mortality was not increased in the morbidly obese group (0.14% vs 0.14%; p = 0.942). Patients who were morbidly obese were more likely to have progressive renal insufficiency (0.30% vs 0.10%; odds ratio [OR], 2.47; 95% CI, 1.27-4.29; p \ 0.001), superficial infection (1.07% vs 0.55%; OR, 1.87; 95% CI, 1.39-2.51; p \ 0.001), and sepsis (0.36% vs 0.23%; OR, 1.70; 95% CI, 1.04-2.53; p = 0.034) compared with patients who were not morbidly obese. Patients who were morbidly obese were less likely to require blood transfusion (8.68% vs One of the authors certifies that he (CLN), or a member of his or her immediate family, has or may receive payments or benefits, during the study period, an amount of USD 10,000-USD 100,000 from Zimmer Inc (Warsaw, IN, USA 12.06%; OR, 0.70; 95% CI, 0.63-0.77; p \ 0.001) compared with patients who were not morbidly obese. Morbid obesity was not associated with any of the other 21 perioperative complications recorded in the NSQIP database. With respect to the composite complication variable...

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Section: Discussionmentioning

confidence: 99%

“…It is not clear whether morbid obesity is truly modifiable, particularly in patients with limited mobility, difficulty exercising, and advanced knee OA. Some surgeons consider morbid obesity to be a relative contraindication to elective TKA [1].…”

Section: Introductionmentioning

confidence: 99%

Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA

Nelson

Elkassabany

Kamath

et al. 2015

Clin Orthop Relat Res

129

View full text Add to dashboard Cite

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“…The ICM workgroup stated that certain conditions such as history of previous surgery, uncontrolled diabetes mellitus (glucose levels > 200 mg/L or HbA1C > 7%), malnutrition, morbid obesity (body mass index > 40 kg/ m2), chronic renal disease, active liver disease, excessive smoking (> one pack per day), exorbitant alcohol use (> 40 units per week), intravenous drug abuse, extended stay in a rehabilitation facility, recent hospitalization, post-traumatic arthritis, inflammatory arthropathy, previous surgical procedure in the affected joint, male gender, and severe immunodeficiency can increase the risk of developing PJI (30).…”

Section: The Icm Commentmentioning

confidence: 99%

Prevention of Periprosthetic Joint Infection

Rezapoor

Parvızı

2015

The Journal of Arthroplasty

116

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“…Only a few of the claims-based comorbidities in our study were found to be significantly associated with surgical site infections, indicating lack of model prediction. Surprisingly, three of four clinically well-recognized risk factors for surgical site infections [1] were not found to be predictive for surgical site infections among patients who underwent TKA. Furthermore, our study cohort possibly had a more severe case mix and was more homogeneous than other large multicenter cohorts-in terms of risk factors and rate of surgical site infections-such as the Medicare population.…”

Section: Discussionmentioning

confidence: 99%

Do Claims-based Comorbidities Adequately Capture Case Mix for Surgical Site Infections?

Kremers

Lewallen

Lahr

et al. 2015

Clinical Orthopaedics &Amp; Related Research

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Background There is increasing interest in using administrative claims data for surveillance of surgical site infections in THAs and TKAs, but the performance of claims-based models for case-mix adjustment has not been well studied. Performance of claims-based models can be improved with the addition of clinical risk factors for surgical site infections. Questions/purposes We assessed (1) discrimination and calibration of claims-based risk-adjustment models for surgical site infections; and (2) the incremental value of adding clinical risk factors to claims-based risk-adjustment models for surgical site infections. Patients and Methods Our study included all THAs and TKAs performed at a large tertiary care hospital from January 1, 2002 to December 31, 2009 (total n = 20,171 procedures). Revision procedures for infections were excluded. Comorbidity data were ascertained through administrative records and classified by the Charlson comorbidity index. Clinical details were obtained from the institutional joint registry and patients' electronic health records. Cox proportional hazards regression models were used to estimate the 1-year risk of surgical site infections with a robust sandwich covariance estimator to account for within-subject correlation of individuals with multiple surgeries. The performance of claims-based risk models with and without the inclusion of four clinical risk factors (morbid obesity, prior nonarthroplasties on the same joint, American Society of Anesthesiologists score, operative time) was assessed using measures of discrimination (C statistic, Somers' D xy rank correlation, and the Nagelkerke R 2 index). Furthermore, calibrations of claims-based risk models with and without clinical factors were assessed graphically by plotting the smoothed trends between model predictions and empirical rates from Kaplan-Meier. Results Discrimination of the claims-based risk models was moderate for the THA (C statistic = 0.662, D xy = 0.325, R 2 = 0.028) and TKA (C statistic = 0.621, D xy = 0.241, R 2 = 0.017) cohorts. Inclusion of four clinical risk factors improved discrimination in both cohorts with significant improvement in the C statistic in the THA cohort (C statistic = 0.043; 95% CI, 0.012-0.074) and in the TKA cohort (C statistic = 0.027; 95% CI, 0.007-0.047). Visual inspection suggested that calibration of the claims-based risk models was adequate and comparable to that of models which included the four additional clinical factors. Conclusions Claims-based risk-adjustment models for surgical site infections in THA and TKA appear to be adequately calibrated but lack predictive discrimination, particularly with TKAs. The addition of clinical risk factors improves the discriminative ability of the models to a moderate degree; however, addition of clinical factors did not change calibrations, as the models showed reasonable

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Mitigation and Education

Cited by 45 publications

References 100 publications

Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA

Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA

Prevention of Periprosthetic Joint Infection

Do Claims-based Comorbidities Adequately Capture Case Mix for Surgical Site Infections?

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