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Purpose: The COVID-19 pandemic had innumerable impacts on healthcare delivery. In Canada, this included limitations on inpatient capacity, which resulted in an increased focus on outpatient surgery for non-emergent cases such as joint replacements. The objective of this study was to assess whether the pandemic and the shift towards outpatient surgery had an impact on access to joint replacement for marginalized patients. Methods: Data from Ontario's administrative healthcare databases were obtained for all patients undergoing an elective hip or knee replacement between January 1, 2018 and August 31, 2021. All surgeries performed before March 15, 2020 were classified as "pre-COVID," while all procedures performed after that date were classified as "post-COVID." The Ontario Marginalization Index domains were used to analyze proportion of marginalized patients undergoing surgery pre- and post-COVID. Results: A total of 102,743 patients were included—42,812 hip replacements and 59,931 knee replacements. There was a significant shift towards outpatient surgery during the post-COVID period (1.1% of all cases pre-COVID to 13.2% post-COVID, p < 0.001). In the post-COVID cohort, there were significantly fewer patients from some marginalized groups, as well as fewer patients with certain co-morbidities, such as congestive heart failure and chronic obstructive pulmonary disease. Conclusion: The most important finding of this population-level database study is that, compared to before the COVID-19 pandemic, there has been a change in the profile of patients undergoing hip and knee replacements in Ontario, specifically across a range of indicators. Fewer marginalized patients are undergoing joint replacement surgery since the COVID-19 pandemic. Further monitoring of access to joint replacement surgery is required in order to ensure that surgery is provided to those who are most in need. [ABSTRACT FROM AUTHOR]

Background: Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. Methods: We performed a retrospective serial cross‐sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population‐representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30‐day readmission rates, and time‐to‐surgery. Results: The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30‐day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%–45%) and THA (0.2%–10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%–60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30‐day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). Conclusions: We observed substantial between‐country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence‐based surgical approaches. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship between patients' expectations for total knee arthroplasty (TKA) and satisfaction with surgical outcome. Methods: This prospective cohort study recruited patients with knee osteoarthritis (OA) ages ≥30 years who were referred for TKA at 2 hip/knee surgery centers in Alberta, Canada. Those who received primary, unilateral TKA completed questionnaires pre‐TKA to assess TKA expectations (17‐item Hospital for Special Surgery [HSS] TKA Expectations questionnaire) and contextual factors (age, sex, Western Ontario and McMaster Universities Osteoarthritis Index pain score, Knee Injury and Osteoarthritis Outcome Score physical function short form [KOOS‐PS], 8‐item Patient Health Questionnaire depression scale, body mass index [BMI], comorbidities, and prior joint replacement), and 1‐year post‐TKA to assess overall satisfaction with TKA results. Using multivariate logistic regression, we examined the relationship between TKA expectations (HSS TKA outcomes considered to be very important) and postoperative satisfaction (very satisfied versus somewhat satisfied versus dissatisfied). Adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. Results: At 1 year, 1,266 patients with TKA (92.1%) reported their TKA satisfaction (mean ± SD age 67.2 ± 8.8 years, 60.9% women, and mean BMI 32.6 kg/m2); 74.7% of patients were very satisfied, 17.1% were somewhat satisfied, and 8.2% were dissatisfied. Controlling for other factors, an expectation of TKA to improve patients' ability to kneel was associated with lower odds of satisfaction (adjusted OR 0.725 [95% CI 0.54–0.98]). An expectation of TKA to improve psychological well‐being was associated with lower odds of satisfaction for individuals in the lowest tertile of pre‐TKA KOOS‐PS scores (adjusted OR 0.49 [95% CI 0.28–0.84]), but higher odds for those in the highest tertile (adjusted OR 2.37 [95% CI 1.33–4.21]). Conclusion: In patients with TKA, preoperative expectations regarding kneeling and psychological well‐being were significantly associated with the level of TKA satisfaction at 1 year. Ensuring that patients' expectations are achievable may enhance appropriate provision of TKA. [ABSTRACT FROM AUTHOR]

Objective: Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are common and effective surgical procedures. This study sought to compare utilization and short‐term outcomes of primary TKA and THA in adjacent regions of Canada and the United States. Methods: The study was designed as a retrospective cohort study of patients who underwent primary TKA or THA, comparing administrative data from New York and Ontario in 2012–2013. Demographic features of the TKA and THA patients, per capita utilization rates, and short‐term outcomes were compared between the jurisdictions. Results: A higher percentage of New York hospitals performed TKA compared to Ontario hospitals (75.7% versus 42.1%; P < 0.001), and the mean annual procedural volume for TKAs was lower in New York hospitals (mean 179 versus 327 in Ontario hospitals; P < 0.001). After direct standardization, utilization was significantly lower in New York compared to Ontario, both for TKA (16.1 TKAs versus 21.4 TKAs per 10,000 population per year; P < 0.001) and for THA (10.5 THAs versus 11.5 THAs per 10,000 population per year; P < 0.001). For those who underwent TKA, the length of stay in Ontario hospitals was significantly longer (mean 3.7 days versus 3.4 days in New York hospitals; P < 0.001). A smaller percentage of New York patients were discharged directly home (46.2% versus 90.9% of Ontario patients; P < 0.001), but 30‐day and 90‐day readmission rates were higher in New York compared to Ontario (30‐day rates, 4.6% versus 3.9% [P < 0.001]; 90‐day rates, 8.4% versus 6.7% [P < 0.001]). For the THA cohorts, the results with regard to length of stay, discharge disposition, and readmission rates were similar to those for TKA. Conclusion: Ontario has higher utilization of total joint arthroplasty than New York but has a smaller percentage of hospitals performing these procedures. Patients are more likely to be discharged home and less likely to be readmitted in Ontario. Our results suggest areas where each jurisdiction could improve. [ABSTRACT FROM AUTHOR]

The objective of this study was to examine the impact of pedestrian countdown signals (PCS) on the rate of motor vehicle collisions (MVCs) in Toronto, Canada. A quasi-experimental design was used to compare rates of single and two vehicle MVCs before and after installation of PCS in Toronto, Canada between January 2005 and December 2009. Collision incidence rates were compared using Poisson regression analyses with adjustment for relevant cofounders and reported as incidence rate ratios (IRR) with 95% confidence intervals (CI). Secondary analyses were performed on subsets of collisions by collision type and injury severity. A total of 94,175 MVCs occurred at or near 1965 intersections at which PCS were installed over the five-year study period. Overall, the MVC incidence rate increased 7.5% (IRR = 1.075; 95% CI: 1.042–1.109;p< 0.0001) after installation of PCS. The installation of PCS led to an increase in MVCs. PCS may have an unintended consequence of increasing the rate of MVCs. [ABSTRACT FROM PUBLISHER]

Objectives: To measure time to flap coverage after open tibia fractures and assess whether delays are associated with inpatient complications., Design: Retrospective cohort study., Setting: One forty level I and II trauma centers in Canada and the United States., Patients/participants: Adult patients (≥16 years) undergoing surgery for (1) an open tibia (including ankle) fracture and (2) a soft-tissue flap during their index admission between January 1, 2012, and December 31, 2015, were eligible for inclusion., Exposure: Time from hospital arrival to definitive flap coverage (in days)., Main Outcome Measurements: The primary outcome was a composite of the following complications occurring during the index admission: (1) deep infection, (2) osteomyelitis, and/or (3) amputation. The primary analysis compared complications between early and delayed coverage groups (≤7 and >7 days, respectively) after matching on propensity scores. We also used logistic regression with time to flap coverage as a continuous variable to examine the impact of the duration of delay on complications., Results: There were 672 patients at 140 centers included. Of these, 412 (61.3%) had delayed coverage (>7 days). Delayed coverage was associated with a significant increase in complications during the index admission after matching (16.7% vs. 6.2%, P < 0.001, number needed to harm = 10). Each additional week of delay was associated with an approximate 40% increased adjusted risk of complications (adjusted odds ratio 1.44, 95% confidence interval 1.13-1.82, for each week coverage was delayed, P = 0.003)., Conclusion: This is the first multicenter study of flap coverage for tibia fractures in North America. Complications rose significantly when flap coverage was delayed beyond 7 days, consistent with current guideline recommendations. Because the majority of patients did not have coverage within this timeframe, initiatives are required to improve care for patients with these injuries., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To identify a cut point in annual surgeon volume associated with increased risk of complications after primary elective total hip arthroplasty and to quantify any risk identified., Design: Propensity score matched cohort study., Setting: Ontario, Canada., Participants: 37,881 people who received their first primary total hip arthroplasty during 2002-09 and were followed for at least two years after their surgery., Main Outcome Measure: The rates of various surgical complications within 90 days (venous thromboembolism, death) and within two years (infection, dislocation, periprosthetic fracture, revision) of surgery., Results: Multivariate splines were developed to visualize the relation between surgeon volume and the risk for various complications. A threshold of 35 cases a year was identified, under which there was an increased risk of dislocation and revision. 6716 patients whose total hip arthroplasty was carried out by surgeons who had done ≤ 35 such procedure in the previous year were successfully matched to patients whose surgeon had carried out more than 35 procedures. Patients in the former group had higher rates of dislocation (1.9% v 1.3%, P=0.006; NNH 172) and revision (1.5% v 1.0%, P=0.03; NNH 204)., Conclusions: In a cohort of first time recipients of total hip arthroplasty, patients whose operation was carried by surgeons who had performed 35 or fewer such procedures in the year before the index procedure were at increased risk for dislocation and early revision. Surgeons should consider performing 35 cases or more a year to minimize the risk for complications. Furthermore, the methods used to visualize the relationship between surgeon volume and the occurrence of complications can be easily applied in any jurisdiction, to help inform and optimize local healthcare delivery., (© Ravi et al 2014.)