Summer 2014


68th Annual Mtg

VOS 68th Annual Meeting
April 24-26, 2015
The Homestead
Hot Springs, VA



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Clinical News

By Quanjun "Trey" Cui, MD
VOS Newsletter Editor

What Strategies are Most Effective at Reducing Readmissions?

A study published online in the journal JAMA Internal Medicine examines strategies for reducing 30-day readmissions. The research team conducted a meta-analysis of 42 randomized trials and found that the most effective interventions were ones that covered many components, involved more individuals in care delivery, and supported patient capacity for self-care. In addition, a post hoc regression model showed incremental value in providing comprehensive, post-discharge support to patients and caregivers. The research team also noted that trials published before 2002 reported interventions that were 1.6 times more effective than those tested later.


Study: Functional Status at Discharge Linked to Likelihood of Readmission

According to information published in the May issue of the Journal of Hospital Medicine, a patient’s functional status near the time of discharge from an acute care hospital may be strongly associated with acute care readmission. The researchers conducted a retrospective cohort study of 9,405 consecutive patients admitted to an inpatient rehabilitation facility from an acute care hospital between July 1, 2006 and December 31, 2012. They found that there were 1,182 readmissions (13 percent), and that Functional Independence Measure (FIM) score was significantly associated with readmission. The relationship between FIM score and readmission held across diagnostic category, with medical patients who had low functional status having the highest readmission rate, compared to medical patients with high FIM scores.


Study: Concussion Diagnosis Rates on the Rise in High School Sports

According to findings published online in The American Journal of Sports Medicine, national concussion diagnosis rates for high school sports increased significantly between 2005 and 2012. The authors used the High School Reporting Information Online sports injury surveillance system to calculate concussion rates over a seven year period. They found that, during the study period, there were 4,024 concussions, with overall concussion diagnosis rates increasing significantly from 0.23 per 1,000 athlete-exposures in academic year 2005-2006 to 0.51 per 1,000 exposures during 2011-2012.


Federal Government to Allow Insurers to Use "Reference Pricing"

The Associated Press reports that the Obama administration has granted approval for insurers and employers to implement a "reference pricing" plan for certain procedures, including hip and knee arthroplasty. Reference pricing allows insurers to place a hard limit on what they will pay for a given procedure, with any excess cost being passed on to the patient. Under the Affordable Care Act, most plans have to pick up the entire cost of care after a patient hits an annual out-of-pocket limit, and observers had noted that it was unclear whether reference pricing would be permitted. Supporters of the move say that reference pricing helps drive the cost of care downward, as patients are more likely to choose less expensive hospitals. Critics point out that reference pricing can leave patients on the hook for high hospital bills, and note that the strategy is most suitable for common procedures and tests that may have wide variation in price but not quality.


Study: Complication Rates After THA, TKA Vary Widely Across Hospitals

Data published in the April 16 issue of The Journal of Bone & Joint Surgery suggest a wide range of complication rates among hospitals that perform elective total hip arthroplasty (THA) and TKA. The researchers conducted a cross-sectional analysis of 878,098 Medicare fee-for-service beneficiaries, aged 65 years or older, who underwent elective THA or TKA across 3,479 hospitals in the United States. They found that the median risk-standardized complication rate averaged 3.6 percent, yet ranged from 1.8 percent to 9.0 percent. The most common complications were pneumonia (0.86 percent), pulmonary embolism (0.75 percent), and periprosthetic joint infection or wound infection (0.67 percent).


Study: Medicaid Patients Often Start in Poorer Health, See Worse Outcomes

Information published online in the journal JAMA Surgery suggests that surgical patients covered by Medicaid are more likely to have poorer health at baseline, see worse outcomes, have longer hospital stays, and are more likely to be readmitted, compared to patients covered by private insurance. The researchers conducted a retrospective review of all adults (nearly 14,000 patients) aged 64 years and younger not covered by Medicare and who underwent inpatient general surgery within the Michigan Surgical Quality Collaborative from July 2012 to June 2013. They found that those with Medicaid coverage were twice as likely as other patients to have certain health risk factors prior to surgery, had more emergency operations, experienced two-thirds more complications after surgery, and used 50 percent more hospital resources than patients with other forms of insurance. In addition, Medicaid patients were twice as likely to smoke, and had higher rates of conditions such as diabetes, lung disease, and blood vessel blockage.


Study: Tamoxifen May Offer Short-term Benefit for Dupuytren Patients Treated
with Surgery

Findings published in the April 16 issue of The Journal of Bone & Joint Surgery suggest that tamoxifen may have a short-term beneficial effect on the outcome of surgery for Dupuytren disease. The authors conducted a prospective, randomized, double-blind study of 26 patients with a strong predisposition toward fibrosis and who were treated with subtotal fasciectomy and either tamoxifen (n = 12) or placebo (n = 14) from six weeks preoperative to three months postoperative. At three-month follow-up, they found that patients in the experimental cohort had a smaller total passive extension deficit and higher satisfaction compared with the placebo group. However, the authors report that the positive effect was lost over two years following cessation of the medication. "Although tamoxifen use should not be considered in every patient with Dupuytren disease," the authors write, "this study does support the development of neoadjuvant pharmacotherapy in patients with a predisposition toward fibrosis."

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Study: Sexual Activity After Total Hip Arthroplasty: A Motion Capture Study

This study published in Journal of Arthroplasty, march issue, volume 29 (3), page 640-647. Relative risk of impingement and joint instability during sexual activities after total hip arthroplasty (THA) has never been objectively investigated. Hip range of motion necessary to perform sexual positions is unknown. A motion capture study with two volunteers was performed. Twelve common sexual positions were captured and relevant hip joint kinematics calculated. This study indicates that some sexual positions could be potentially at risk after THA, particularly for women (Figure below).

Clinical News

Sexual positions for men and women recommended after THA. In all images, the man is represented in blue and the woman in pink. A cross next to each symbol means that the position should be avoided; a tick means that the position is allowed


Study: Physical Therapy May Not Improve Pain, Function in Patients With Hip OA.

As reported by Medical News Today, a study recently published in the Journal of the American Medical Association finds that patients with painful hip osteoarthritis (OA) who underwent physical therapy did not have greater improvement in pain or function than patients with painful hip OA who received sham treatment. The randomized, placebo-controlled, participant- and assessor-blinded trial involved 102 community volunteers with hip OA confirmed by radiograph and hip pain levels of at least 40 on a visual analog scale of 0–100 (100 indicates worst pain possible). Forty-nine patients were placed in the “active” group and received education and advice, manual therapy, home exercise, and gait aid, if appropriate. Fifty-three patients were placed in the “sham” group and received inactive ultrasound and inert gel. All patients underwent 12 weeks of intervention and 24 weeks of follow up (May 2010–February 2013). Patients in the active group continued unsupervised home exercise for 24 weeks after treatment, while participants in the sham group self-applied gel three times weekly during that 24-week period. The researchers found that, at 13 and 36 weeks, the active treatment did not lead to additional benefits compared with sham treatment as measured by pain and physical function scores, which had improved in both groups. The active group, however, had significantly more adverse events; 41 percent of patients in the active group reported a total of 26 mild adverse events and 14 percent of those in the sham group reported a total of nine mild adverse events.