FACTORS ASSOCIATED WITH ADVERSE EVENTS IN MAJOR ELECTIVE SPINE, KNEE, AND HIP INPATIENT ORTHOPAEDIC SURGERY

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1 FACTORS ASSOCIATED WITH ADVERSE EVENTS IN MAJOR ELECTIVE SPINE, KNEE, AND HIP INPATIENT ORTHOPAEDIC SURGERY Dov B. Millstone, Anthony V. Perruccio, Elizabeth M. Badley, Y. Raja Rampersaud Dalla Lana School of Public Health, University of Toronto Toronto Western Research Institute and Toronto Western Hospital, University Health Network

2 Outline Background Adverse Event Definition Purpose Adverse Event Capture Methods Results Discussion

3 Background per 100,000 knee replacements and per 100,000 hip replacements in Canada per 100,000 knee replacements, per 100,000 hip replacements, and per 100,000 spinal fusions in the United States 2 While inpatient hospitalizations have steadily decreased in Canada, knee and hip replacements continue on an upward trend Spine fusions, knee replacements, and hip replacements rank 1 st, 2 nd, and 5 th in the U.S. with respect to the National Bill 2

4 Adverse Events Any undesirable event caused by medical or surgical management, not by the underlying disease process or injury 3 Negative physical and psychological consequences 4,5 Associated with increased costs 6-8 Increased lengths of stay Additional resources for care

5 Purpose What factors are associated with adverse events in knee, hip, and spine orthopaedic surgery patients with osteoarthritis?

6 Adverse Event Capture Inconsistent terminology Adverse event vs. complication Ambiguous terminology (e.g., major and minor) Inconsistent capture methods Administrative data ICD codes Focus on specific adverse events and/or subpopulations

7 Ortho-SAVES Orthopaedic Surgical AdVerse Event Severity system Based on previously validated system for spine surgery 3 17 intra-operative, 34 post-operative adverse events Severity grading from 1-6

8 Methods Prospective cohort study All orthopaedic surgeries over two years Two personnel oversaw completion of Ortho-SAVES form Other factors extracted from hospital charts Procedure/site, diagnosis, age, sex, BMI, ASA score, comorbidities, procedure time, primary/revision Analysis Descriptive statistics Multivariable logistic regression

9 Results - 1 n = 2, spine, 706 hip, & 998 knee surgeries Mean age: 64.6 (±11.7), 55% female Mean procedure time: 91.9 minutes Hip procedure time: 62.8 minutes Knee procedure time: 70.9 minutes Spine procedure time: minutes Experienced an adverse event: 27% Hip adverse events: 25% Knee adverse events: 27% Spine adverse events: 29%

10 Results - 2 Worst AE Multiple AEs Site Grade 1 or 2 Grade 3+ P Value No Yes P Value Spine 106 (83%) 22 (17%) < (73%) 35 (27%) < Hip 160 (92%) 14 (8%) 159 (91%) 16 (9%) Knee 237 (89%) 29 (11%) 229 (86%) 37 (14%) Spine top 5 AEs Hip top 5 AEs Knee top 5 AEs AE % of spine AEs AE % of hip AEs AE % of knee AEs Dural tear 28.5% Urinary 60.6% Urinary retention 56.0% retention UTI 20.8% Delirium/altered 6.8% Pulmonary 8.3% mental state embolism Urinary retention 19.2% Fall 2.3% Cardiac arrest/ 6.4% failure/arrhythmia Delirium/altered 5.4% Ileus/bowel 2.3% Delirium/altered 6.0% mental state obstruction mental state Superficial wound infection 4.6% Deep wound infection 2.3% Superficial wound infection 3.4%

11 Results - 3 Model 1 Model 2 Variable Age Per 15 year interval Occurrence of AE vs. not Odds Ratio (95% CI) P Value Occurrence of AE vs. not Odds Ratio (95% CI) P Value 1.29 ( ) < ( ) <0.001 Male vs. Female 1.40 ( ) < ( ) <0.01 Spine Surgery vs. Knee 0.98 ( ) ( ) <0.01 Hip Surgery vs. Knee 0.90 ( ) ( ) 0.60 Overweight vs. Normal 0.76 ( ) ( ) <0.05 Obese vs. Normal 0.81 ( ) ( ) 0.07 ASA class 3/4 vs. 1/ ( ) ( ) 0.32 Revision surgery vs. Primary 2.29 ( ) < ( ) <0.01 Procedure Time Per 30 min ( ) < High Blood Pressure vs. no 0.85 ( ) ( ) 0.12 Diabetes vs. no 1.25 ( ) ( ) 0.08 CVD vs. no 0.97 ( ) ( ) 0.92 High Cholesterol vs. no 1.05 ( ) ( ) 0.68 Other Medical vs. no 1.19 ( ) ( ) 0.26

12 Discussion Replication of previous result Age, male sex, revision surgery, longer procedure time are risk factors Higher adverse event rate than previous reports Spine surgery lower odds of having an AE after adjusting for time Overweight BMI lower odds compared to normal weight

13 Implications Most adverse events were minor Need to focus on preventing these Future Directions What cost is associated with adverse events? In particular, what cost is associated with minor events?

14 Strengths & Limitations Strengths Othro-SAVES system Comparison of multiple surgical sites in one model Multiple risk factors captured from charts Limitations Single site Focus on in-hospital adverse events

15 References 1. Canadian Institute for Health Information. Hip and Knee Replacements in Canada: Canadian Joint Replacement Registry 2014 Annual Report. Toronto, Ontario: Canadian Institute for Health Information; Report No.: Agency for Healthcare Research and Quality. National and regional estimates on hospital use for all patients from the HCUP Nationwide Inpatient Sample (NIS). Maryland: U.S. Department of Health and Human Services; Rampersaud YR, Neary MA, White K. Spine adverse events severity system: Content validation and interobserver reliability assessment. Spine. 2010;35(7): Institute of Medicine. To Err Is Human Building a Safer Health System. Washington, DC: National Academy Press; Institute of Medicine. Patient safety : achieving a new standard for care. Aspden P, Institute of Medicine (U.S.)., editors. Washington, D.C.: National Academies Press; Hellsten EK, Hanbidge MA, Manos AN, Lewis SJ, Massicotte EM, Fehlings MG, Coyte PC, Rampersaud YR. An economic evaluation of perioperative adverse events associated with spinal surgery. The Spine Journal ;13(1): Memtsoudis SG, Della Valle AG, Besculides MC, Gaber L, Laskin R. Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. J Arthroplasty Jun;24(4): Maradit Kremers H, Visscher SL, Moriarty JP, Reinalda MS, Kremers WK, Naessens JM, Lewallen DG. Determinants of direct medical costs in primary and revision total knee arthroplasty. Clin Orthop Relat Res Jan;471(1): AVP15

16 Slide 15 AVP15 wonder whether you don't want to include the relevant refs on the slides to which they pertain. Anthony Perruccio, 5/21/2015

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