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Background: Increasing demand for shoulder arthroplasty and an aging population may increase the rate of complications associated with advanced age such as postoperative delirium, but little is known on its burden in this cohort. Purpose: We sought to answer the following questions: (1) What is the epidemiology of postoperative delirium after shoulder arthroplasty? (2) What modifiable risk factors can be identified for postoperative delirium after shoulder arthroplasty? (3) Do risk factors differ in those younger than and in those older than 70 years of age? Methods: In a retrospective nationwide cohort study, we extracted data from the Premier Healthcare database on inpatient total and reverse shoulder arthroplasties from 2006 to 2016. The primary outcome was postoperative delirium; modifiable risk factors of interest were perioperative opioid use (high, medium, or low), peripheral nerve block use, and perioperative prescription medications. Mixed-effects models assessed associations between risk factors and postoperative delirium. Odds ratios and confidence intervals are reported. We applied a cutoff of 70 years of age because it was the median age of the cohort, as well as the age at which we observed that delirium prevalence increased. Results: A total of 92,429 total and reverse shoulder arthroplasties were identified (age range: 14–89 years). Overall delirium prevalence was 3.1% ( n = 2909). Age-specific prevalence of postoperative delirium was lower in patients aged 50 to 70 years and higher in those aged 70 years and older, up to 8% among those older than 88 years. After adjusting for relevant covariates, only long-acting and combined short-acting and long-acting benzodiazepines (compared with no benzodiazepines) were associated with increased odds of postoperative delirium. Corticosteroids were associated with decreased odds of postoperative delirium. Conclusion: Our retrospective cohort study demonstrated that benzodiazepine use and older patient age were significantly associated with postoperative delirium in shoulder arthroplasty patients. The relationship between benzodiazepine use and delirium was particularly notable among those 70 years of age and older. Further investigation is indicated, given the known adverse effects of benzodiazepines in older adults and our findings of higher than expected use of these medications in this surgical cohort.

Despite the extensive literature on racial disparities in care and outcomes after total knee arthroplasty (TKA), data on manipulation under anesthesia (MUA) is lacking. We aimed to determine (1) the relationship between race and rate of (and time to) MUA after TKA, and (2) annual trends in racial differences in MUA from 2013 to 2018.This retrospective cohort study (using 2013-2018 Medicare Limited Data Set claims data) included 836,054 primary TKA patients. The primary outcome was MUA1 year after TKA; time from TKA to MUA in days was also recorded. A mixed-effects multivariable model measured the association between race (White, Black, Other) and odds of MUA. Odds ratios (OR) and 95% confidence intervals (CI) were reported. A Cochran Armitage Trend test was conducted to assess MUA trends over time, stratified by race.MUA after TKA occurred in 1.7%, 3.2% and 2.1% of White, Black, and Other race categories, respectively (SMD = 0.07). After adjustment for covariates, (Black vs White) patients had increased odds of requiring an MUA after TKA: odds ratio (OR) 1.97, 95% confidence intervals (CI) 1.86-2.10, P.0001. Moreover, White (compared to Black) patients had significantly shorter time to MUA after TKA: 60 days (interquartile range [IQR] 46-88) versus 64 days (interquartile range [IQR] 47-96); P.0001. These disparities persisted from 2013 through 2018.Continued racial differences exist for rates and timing of MUA following TKA signifying the continued need for efforts aimed toward understanding and eliminating inequalities that exist in total joint arthroplasty (TJA) care.

Background: Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described. Purpose: To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017. Study Design: Descriptive epidemiology study. Methods: For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement. Results: There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all). Conclusion: Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.

Fluoroquinolone prophylaxis is recommended during induction chemotherapy for patients with acute myeloid leukemia (AML) to reduce risk of neutropenic fever and systemic bacterial infections. We evaluated the effectiveness of primary fluoroquinolone prophylaxis in an area with high fluoroquinolone resistance.We performed a retrospective chart review of newly diagnosed adult AML patients who received frontline therapy at Mount Sinai Hospital in New York, NY, between 2012 and 2019. Primary outcome was development of neutropenic fever. Secondary outcomes were development of systemic bacterial infections and infections with multidrug-resistant organisms and Clostridioides difficile. Infectious outcomes were collected through 6 months after therapy initiation. We estimated the effect of fluoroquinolone prophylaxis with a time-dependent Cox proportional hazards model.Of 121 included patients, 87 received antibiotic prophylaxis and 34 did not. There was no difference in baseline characteristics, although the prophylaxis group had longer neutropenia duration (median 30 vs. 23 days, P = .013). The prophylaxis group had a reduced risk of neutropenic fever (hazard ratio 0.59, P = .039). The prophylaxis group had fewer gram-positive (P = .043) and gram-negative (P = .049) bloodstream infections and fewer clinically documented infections during frontline therapy (P = .005) and follow-up (P = .026). There was no difference in incidence of C. difficile or infection with fluoroquinolone-resistant or multidrug-resistant organisms. There was no mortality difference between groups.In an area with high fluoroquinolone resistance, primary fluoroquinolone prophylaxis in newly diagnosed AML patients reduced the risk of neutropenic fever and systemic bacterial infections without increased antimicrobial resistance. Prospective, randomized studies are needed to confirm these observations.

Anagrelide (ANA) is a platelet-specific cytoreductive agent utilized in the guideline-directed management of high-risk essential thrombocythemia. In the context of polycythemia vera (PV), ANA is occasionally employed in clinical practice, although data has not consistently demonstrated a benefit to targeting a platelet goal as a therapeutic endpoint. The aim of the current study was to delineate the patterns of ANA use in PV, and to describe outcomes and toxicities. Within a multi-center cohort of 527 patients with PV, 48 received ANA (9 excluded for absent data). 27 (69.2%) had high-risk PV, 10 (25.6%) had prior thrombosis, and none had extreme thrombocytosis, acquired von Willebrand disease, and/or documented resistance to hydroxyurea. While ANA effectively lowered median platelet count, 43.5% of patients had an unresolved thrombocytosis at time of ANA discontinuation. Treatment-emergent adverse events-including headaches, cardiac palpitations and arrhythmias, nausea, vomiting and/or diarrhea-led to ANA discontinuation in 76.9% of patients. Further, three patients experienced arterial thromboses during a median duration of 27.5 months of ANA therapy. In conclusion, this study highlights ANA's restrictive tolerability profile which, compounded by the absence of clear advantage to strict platelet control in PV, suggests the use of ANA should be limited in this setting.

After the suspension of elective surgeries was lifted in June 2020 in New York State, challenges remained regarding coordination of total joint arthroplasty (TJA) cases. Using the experience from a high-volume health system in New York City, we aimed to describe patterns of care after resumption of elective TJA.We retrospectively assessed 7,699 TJAs performed before and during the COVID-19 pandemic. Perioperative characteristics and clinical outcomes were compared between TJAs based on time period of performance: 1) pre-pandemic (PP, June 8th-December 8th, 2019), 2) initial period post-resumption of elective surgeries (IR, June 8th-September 8th, 2020), and 3) later period post-resumption (LR, September 9th-December 8th, 2020).LOS 2 days (83%, 67%, 70% for PP, IR, LR periods respectively) and discharge rates to post-acute care (PAC) facilities were lower during the pandemic periods (ORDespite decreased LOS and discharge to PAC for TJAs performed during the pandemic, 30-day readmissions did not increase. Given the increased costs and lack of superior functional outcomes associated with discharge to PAC, these findings suggest that discharge to PAC facilities need not return to pre-pandemic levels.

Provider-run "joint classes" educate total joint arthroplasty (TJA) patients on how to best prepare for surgery and maximize recovery. There is no research on potential healthcare inequities in the context of joint classes or on the impact of the recent shift toward telehealth due to coronavirus disease 2019 (COVID-19). Using data from a large metropolitan health system, we aimed to (1) identify demographic patterns in prepandemic joint class attendance and (2) understand the impact of telehealth on attendance.We included data on 3,090 TJA patients from three centers, each with a separately operated joint class. Attendance patterns were assessed prepandemic and after the resumption of elective surgeries when classes transitioned to telehealth. Statistical testing included standardized differences (SD0.1 indicates significance) and a multivariate linear regression.The in-person and telehealth attendance rates were 69.9% and 69.2%, respectively. Joint class attendance was significantly higher for non-White, Hispanic, non-English primary language, Medicaid, and Medicare patients (all SD0.1). Age was a determinant of attendance for telehealth (SD0.1) but not for in-person (SD = 0.04). Contrastingly, physical distance from hospital was significant for in-person (SD0.1) but not for telehealth (SD = 0.06). On a multivariate analysis, distance from hospital (P.05) and telehealth (P.0001) were predictors of failed class attendance.This work highlights the relative importance of joint classes in specific subgroups of patients. Although telehealth attendance was lower, telehealth alleviated barriers to access related to physical distance but increased barriers for older patients. These results can guide providers on preoperative education and the implementation of telehealth.

Background: While the comprehensive care for joint replacement (CJR) bundled payment program for total joint replacement (TJR) emphasizes value, concerns persist regarding unintended consequences, primarily hospital selection of healthier, younger patients. Purpose: We sought to assess changes in patient characteristics and outcomes after CJR implementation in New York State. Methods: This retrospective cohort study included primary total hip and total knee arthroplasties from the New York Statewide Planning and Research Cooperative System (SPARCS) database. Procedures performed before (July 2014 to March 2016; n = 58,610) and after (April 2016 to December 2017; n = 78,728) CJR implementation were compared. Primary outcomes were patient characteristics: Deyo-Comorbidity Index and age. Secondary outcomes were increased hospitalization cost, discharge to institutional post-acute care, and prolonged length of stay. A difference-in-differences analysis estimated changes after CJR implementation, comparing CJR to non-CJR hospitals. Results: We found that CJR implementation (in 49 of 144 New York State hospitals) coincided with slightly older and more comorbid TJR recipients. The CJR program coincided with significantly reduced hospitalization cost and discharge to institutional post-acute care but not length of stay. Some CJR effects appear to have affected non-Medicare patients, as well. Conclusion: This retrospective analysis suggests that in New York State, the CJR bundled payment program did not result in hospitals selecting younger and healthier TJR recipients and coincided with decreased costs and fewer discharges to institutional postacute care.

Background: The demand for total ankle arthroplasty (TAA) and ankle arthrodesis surgery is increasing. Findings from other orthopaedic populations suggest an increasing comorbidity burden among those planned for surgery, however, data on TAA and ankle arthrodesis is limited. The goal of this study is to study the comorbidity burden for TAA and ankle arthrodesis. Hypothesis: Comorbidity burden is associated with higher resource utilization for both TAA and ankle arthrodesis. Patients and Methods: This retrospective cohort study utilized data from the nationwide Premier Healthcare Database (2006-2016) which contains inpatient claims on N=10,085 ankle arthrodesis and N=4,977 TAA procedures. Patients were categorized into Deyo-Charlson comorbidity index (DCCI) groups. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization, discharge to a skilled nursing facility (SNF), and 30-day readmission. Mixed-effects models estimated associations between DCCI and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI). Results: In the TAA group, 67.9% of patients were in DCCI category 0 while 22.4%, 6.6%, and 3.1% were in the 1, 2, and >2 DCCI categories, respectively. This was 61.3%, 18.1%, 9.8% and 10.9% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus, and chronic pulmonary disease. Particularly in the ankle arthrodesis group, the proportion of patients with comorbidities has increased over time. After adjustment for relevant covariates, patients in the DCCI group >2 (compared to ‘0’) were associated with stepwise effects of up to 77.1% (CI 70.9%; 83.6%) longer length of stay and up to 48.5% (CI 44.0%; 53.2%) higher cost of hospitalization. Discussions: Comorbidity burden is increasing among patients undergoing ankle arthrodesis where it is associated with significantly increased resource utilization. Our data demonstrate the potential impact of patient selection, which may be crucial in optimizing preoperative status. Level of Evidence: III