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To report on our institution's first year of experience with a preferred vendor program for implants and disposables for sports medicine surgery.Cost and utilization data for implants and disposables were analyzed for knee and shoulder sports medicine surgeries performed during the 2-year period including the 12 months preceding the start of the contract (contract year 0 [CY0] and the first 12 months of the contract period (CY1). The costs of grafts and biological therapies were excluded. Utilization of the preferred vendor's products, operative time, and per-case costs were compared between the 2 time periods and adjusted for patient factors and case mix.Utilization of the preferred vendor's shavers (0% to 94%, P.001) and radiofrequency ablation wands (0% to 91%, P.001) increased significantly in CY1 (n = 5,068 cases) compared with CY0 (n = 5,409 cases), with a small but significant increase in use of the preferred vendor's implants (64% to 67%, P = .023). There was no significant difference in mean operative time between CY0 and CY1 (P = .485). Mean total per-case implant and disposable costs decreased by 12% (P.001) in CY1 versus CY0.Our institution was able to reduce the costs of sports medicine surgery with the implementation of a preferred single-vendor program for implants and disposables. This program had widespread surgeon adoption and did not have any detrimental effect on operating room efficiency.III, retrospective comparative study.

The Latarjet-Patte procedure has a long and storied history that predates shoulder arthroscopy, but its popularity has increased over the past two decades as a treatment for anterior glenohumeral instability with bone loss. Transfer of the coracoid process and conjoint tendon to the anteroinferior glenoid creates a triple-blocking effect that is both static and dynamic, lending it biomechanical superiority over alternative bone block techniques. Patients undergoing the Latarjet-Patte procedure have low rates of recurrent instability compared to arthroscopic soft-tissue stabilization procedures, particularly in the setting of glenoid- and humeral-sided bone loss. A number of technical innovations have been developed in recent years to improve the efficacy of this procedure and to reduce its potential complications, although their associated learning curves and potential for widespread adoption remain unclear. In this article, we review the history, indications, outcomes, and future of this surgical technique.

Private hospital rooms have a number of potential advantages compared to shared rooms, including reduced noise and increased control over the hospital environment. However, the association of room type with patient experience metrics in total joint arthroplasty (TJA) patients is currently unclear.For private versus shared rooms, we compared our institutional Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in patients who underwent primary TJA over a 2-year period. Regression model odds ratios (ORs) were adjusted for surgeon, date of surgery, and length of stay.Patients in private rooms were more likely to report a top-box score for overall hospital rating (85.6% vs 79.4%, OR = 1.53, P = .011), hospital recommendation (89.3% vs 83.0%, OR = 1.78, P = .002), call button help (76.0% vs 68.7%, OR = 1.40, P = .028), and quietness (70.4% vs 59.0%, OR = 1.78, P.001). There were no significant differences on surgeon metrics including listening (P = .225), explanations (P = .066), or treatment with courtesy and respect (P = .396).For patients undergoing TJA, private hospital rooms were associated with superior performance on patient experience metrics. This association appears specific for global and hospital-related metrics, with little impact on surgeon evaluations. With the utilization of HCAHPS data in value-based initiatives, placement of TJA patients in private rooms may lead to increased reimbursement and higher hospital rankings.Level III, retrospective cohort.

The transition to bundled payment reimbursement for geriatric hip fractures has incentivized the identification of avoidable inefficiencies in the cost and quality of care. Although a "weekend effect" has been described with regard to hip fracture mortality, measures of efficiency according to the day of hip fracture admission are currently unclear.We identified 62,303 patients aged 65 years or older with a primary diagnosis of femoral neck or intertrochanteric hip fracture in the New York Statewide Planning and Research Cooperative System between 2009 and 2014. Outcome measures included preoperative delay, postoperative length of stay (LOS), and cost of admission.Preoperative delay was longer for weekend admissions, but shorter for admissions on Wednesday, Thursday, and Friday. Postoperative LOS was longer for admissions on Tuesday, Wednesday, and Thursday. Discharge rates varied considerably according to the day of admission, ranging from 12% to 43% by hospital day 4 and 53% to 72% by hospital day 6. No differences in cost according to day of admission were found once preoperative delay and postoperative LOS were accounted for.Notable variation exists in hospitalizations for geriatric hip fracture depending on the day of admission. Our data suggest the presence of a weekend effect, in which changes in staffing of surgical, medical, and ancillary services lead to increased waiting times for surgery for new admissions and delays in discharge of early- and mid-week admissions.Level III, retrospective study.

In recent years, narcotics have been subject to increased regulation and monitoring because of their side effects and potential for misuse. Currently, variation in prescribing patterns of narcotics among orthopedic surgeons is unknown. The Medicare Part D claims database was used to identify orthopedic surgeons who prescribed at least one schedule II or III narcotic during 2014. The median duration of a narcotic prescription was 8.2 days. The median prescription duration was shortest for hand surgeons (5.6 days) and longest for spine surgeons (12.6 days). Orthopedic surgeons in New York (10.1 days) provided the most narcotics per prescription, with physicians in Vermont (6.2 days) providing the least. Substantial variation exists in narcotic prescribing patterns for orthopedic surgeons at the individual, subspecialty, and statewide levels. With public health focus on reducing narcotics abuse, physician stewardship of these medications will become increasingly relevant.

Background For patients undergoing total elbow arthroplasty (TEA), the present study aimed to investigate: (i) what risk factors are associated with periprosthetic elbow infection; (ii) what is the incidence of infection after TEA; and (iii) what is the acuity with which these infections present? Methods The Statewide Planning and Research Cooperative System database was used to identify all patients who underwent TEA between 2003 and 2012 in New York State. Admissions for prosthetic joint infection (PJI) were identified using ICD-9 (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code 996.66. Multivariate analysis was used to determine risk factors that were independently prognostic for PJI. Results Significant risk factors for PJI included hypothyroidism [odds ratio (OR) = 2.04; p = 0.045], tobacco use disorder (OR = 3.39; p = 0.003) and rheumatoid arthritis (OR = 3.31; p Conclusions Pre-operative optimization of thyroid function, smoking cessation and management of rheumatoid disease may be considered in surgical candidates for TEA. The results of the present study add prognostic data to the literature that may be helpful with patient selection and risk profile analysis. Level of evidence Level III: prognostic study

Atrial septal defect (ASD) and patent foramen ovale (PFO) are 2 of the most common congenital heart diseases in adults and pose important risks of perioperative acute ischemic stroke (AIS) from paradoxical emboli. We evaluated the following: (1) the prevalence of ASD/PFO in the total hip arthroplasty (THA) population; (2) the rate of perioperative AIS during index admissions; and (3) the risk for perioperative AIS after THA for patients with ASD/PFO vs matched controls.We identified 393,652 patients in the Nationwide Inpatient Sample who underwent THA between January 1, 2007, and December 31, 2013. The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were used to identify patients with ASD/PFO and perioperative AIS. Propensity scores matched 252 patients with ASD/PFO to 756 controls (3:1 ratio) without ASD/PFO according to age, gender, race, Deyo comorbidity score, year of surgery, and stroke risk factors. Logistic regression models assessed risk for perioperative AIS.The prevalence of ASD/PFO was 64 per 100,000 THA patients. The rate of perioperative AIS was 99 per 100,000 THA in the general THA population. The rate of perioperative AIS was 7.14% for ASD/PFO patients compared with 0.26% in matched controls (P.001). Risk for perioperative AIS was 29 times greater for patients with ASD/PFO compared with matched controls (odds ratio, 29.00; 95% confidence interval, 6.68-125.89; P.001).Patients with ASD/PFO undergoing THA are at a significantly higher risk of perioperative AIS. Orthopedic surgeons should discuss this risk with patients before surgery. The efficacy of mechanical and pharmacologic thromboprophylactic measures to reduce perioperative AIS among ASD/PFO patients warrants further investigation.

Venous thromboembolic disease (VTED) is a serious complication of primary and revision total knee arthroplasty (TKA). However, the incidence and risk of VTED for revision compared with primary TKA cases have not been well-described.We identified 225,584 TKAs (208,954 primaries, 16,630 revisions) in the 2003-2012 Statewide Planning and Research Cooperative System database. Odds ratios (ORs) expressed the risk of VTED for revision vs primary TKA, and models were adjusted for age, gender, race, and Charlson comorbidity scores. Outcome analyses were further stratified into deep venous thromboses (DVTs) and pulmonary emboli (PEs).The incidence of VTED within 30 days was 2.24% for primary and 1.84% for revision. In multivariable-adjusted regression, the OR of VTED within 30 days for revision compared with primary was 0.81 (95% confidence interval = 0.72-0.91; P.001). The incidence of VTED within 90 days was 2.42% for primary and 2.13% for revision (P = .022), with a multivariable-adjusted OR of 0.87 (95% confidence interval = 0.78-0.97; P = .010) for revision compared with primary. The association was stronger for PE (OR = 0.63; P.001) than DVT (OR = 0.87; P = .035) at 30 days, and significant for PE (OR = 0.69; P.001), but not DVT (OR = 0.94; P = .284) at 90 days.In a large statewide database, the risk of VTED was lower for revision TKA compared with primary TKA. The reasons for this observation are not known, but might be related to aggressive prophylactic management of patients undergoing revision procedures. Future studies should attempt to clarify differences in patient selection and management for primary vs revision procedures.

The number of patients living with human immunodeficiency virus and acquired immunodeficiency syndrome is growing due to advances in antiretroviral therapy. Existing literature on appendectomy within this patient population has been limited by small sample sizes. Therefore, we used a large, multiyear, nationwide database to study this topic comprehensively.Using the Nationwide Inpatient Sample, we identified 338,805 patients between 2005 and 2012 who underwent laparoscopic or open appendectomy for acute appendicitis. Interval appendectomies were excluded. We used multivariable adjusted regression models to test differences between patients with human immunodeficiency virus without acquired immunodeficiency syndrome and a reference group, as well as human immunodeficiency virus with acquired immunodeficiency syndrome and a reference group, with regard to duration of stay, hospital charges, in-hospital complications, and in-hospital mortality. Models were adjusted for patient age, sex, race, insurance, socioeconomic status, Elixhauser comorbidity score, and appendix perforation.There were 1,291 (0.38%) patients with human immunodeficiency virus, among which 497 (0.15%) patients had acquired immunodeficiency syndrome. In regression analysis, human immunodeficiency virus alone was not associated with adverse outcomes, while acquired immunodeficiency syndrome alone was associated with longer duration of stay (incidence rate ratio 1.40 [1.37-1.57 95% confidence interval], P .0001), increased total charges (exponentiated coefficient 1.16 [1.10-1.23 95% confidence interval], P .0001), and increased risk of postoperative infection (odds ratio 2.12 [1.44-3.13 95% confidence interval], P = .0002).Patients with acquired immunodeficiency syndrome who undergo appendectomy for acute appendicitis are subject to longer and more expensive hospital admissions and have greater rates of postoperative infections while patients with human immunodeficiency virus alone are not at risk for adverse outcomes.

Patient satisfaction is publicly reported and used as a subjective measure of quality of care in alternative payment reimbursement models. In this study, we evaluated the association between patient satisfaction scores and objective measures of geriatric hip fracture care. Therefore, according to patient satisfaction score, we investigated the differences for geriatric hip fracture admissions in regard to 1. surgical delay during the index admission and 2. mortality within 1 year.We identified 65,974 patients between the ages of 60 and 99 years with a primary diagnosis of femoral neck fracture in the New York Statewide Planning and Research Cooperative System database from 2009 to 2014. We evaluated patient satisfaction using annual hospital HCAHPS scores reported on Hospital Compare. Mixed effects regression models controlled for hospital and year of surgery as random effects variables and categorical age, sex, race, insurance, categorical Deyo score, fracture location, and surgical procedure as fixed effects variables.For high compared to low patient satisfaction hospitals, there were shorter surgical delays (β: -60%, 95% CI: -66% to -52%, p0.001) and a lower risk of 1-year mortality (OR: 0.86, 95% CI: 0.78 to 0.93, p0.001). For middle compared to low patient satisfaction hospitals, there were shorter surgical delays (β: -37%, 95% CI: -46% to -26%, p0.001), but no significant difference in 1-year mortality (OR: 0.94; 95% CI: 0.87 to 1.01; p = 0.091).Subjective quality, as measured by HCAHPS patient satisfaction scores, is associated with objective quality and clinical outcomes in geriatric hip fracture care. While these findings support the use of patient experience as a component of quality measurement, it remains unclear whether a superior patient experience in itself can increase the value of health care for patients in the form of superior clinical outcomes or if it will lead to increased strain on hospital resources and increase the cost of services, which would paradoxically decrease the value of care.

In total joint arthroplasty, variation in implant use can be driven by vendor relationships, surgeon preference, and technological advancements. Our institution developed a preferred single-vendor program for primary hip and knee arthroplasty. We hypothesized that this initiative would decrease implant costs without compromising performance on quality metrics.The utilization of implants from the preferred vendor was evaluated for the first 12 months of the contract (September 1, 2017, to August 31, 2018; n = 4,246 cases) compared with the prior year (September 1, 2016, to August 31, 2017; n = 3,586 cases). Per-case implant costs were compared using means and independent-samples t tests. Performance on quality metrics, including 30-day readmission, 30-day surgical site infection (SSI), and length of stay (LOS), was compared using multivariable-adjusted regression models.The utilization of implants from the preferred vendor increased from 50% to 69% (p0.001), with greater use of knee implants than hip implants from the preferred vendor, although significant growth was seen for both (from 62% to 81% for knee, p0.001; and from 38% to 58% for hip, p0.001). Adoption of the preferred-vendor initiative was greatest among low-volume surgeons (from 22% to 87%; p0.001) and lowest among very high-volume surgeons (from 61% to 62%; p = 0.573). For cases in which implants from the preferred vendor were utilized, the mean cost per case decreased by 23% in the program's first year (p0.001), with an associated 11% decrease in the standard deviation. Among all cases, there were no significant changes with respect to 30-day readmission (p = 0.449) or SSI (p = 0.059), while mean LOS decreased in the program's first year (p0.001).The creation of a preferred single-vendor model for hip and knee arthroplasty implants led to significant cost savings and decreased cost variability within the program's first year. Higher-volume surgeons were less likely to modify their implant choice than were lower-volume surgeons. Despite the potential learning curve associated with changes in surgical implants, there was no difference in short-term quality metrics.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION Magnet Recognition is the highest distinction a healthcare organization can receive for excellence in nursing. Although Magnet status is generally associated with superior clinical outcomes and patient satisfaction, its association with performance on nationwide quality metrics is currently unknown. METHODS Within a propensity score-matched cohort, we compared performance on the Hospital-Acquired Condition Reduction Program (HACRP), Hospital Value-Based Purchasing (VBP), and Hospital Readmissions Reduction Program (RRP) initiatives. RESULTS The mean HACRP total performance score was inferior at Magnet versus non-Magnet hospitals (p < .001), and HACRP penalties were more likely to be levied against Magnet hospitals (p = .003). There was no significant difference according to Magnet status for VBP penalties after correcting for multiple comparisons (p = .049). There were no significant difference in RRP penalties according to Magnet status (p = .999). CONCLUSIONS Magnet hospitals performed worse on a number of hospitalwide quality metrics tied to reimbursement by the Centers for Medicare and Medicaid Service. Although Magnet hospitals are known for superior nursing care and organizational support for safety and quality improvement, this is not captured within these composite measures of quality, which can be influenced at many levels of care. These data underscore the need for comprehensive quality improvement across multiple domains of care outside of nursing. LEVEL OF EVIDENCE Level III, retrospective study.

Background Hemophilia can lead to the development of arthropathies secondary to recurrent hemarthroses. However, given these patients' bleeding tendencies, postoperative complications associated with blood loss are a considerable concern. Methods We identified men in the Nationwide Inpatient Sample who underwent total hip or knee arthroplasty between January 1998 and December 2010. We used propensity scores to match 332 hemophiliacs (267 hemophilia A, 65 hemophilia B) to a comparison cohort of 996 patients in a 1:3 ratio, according to the site of arthroplasty, year of admission, age, race, and Charlson and Deyo score. Results The incidence of any postoperative transfusion was 15.06% for hemophiliacs, compared with 9.84% for the matched comparison cohort ( P = .012). For hemophiliacs, the odds ratio was 1.60 (95% confidence interval [CI] = 1.11-2.31; P = .013) for any transfusion, 1.90 (95% CI = 1.24-2.92; P = .003) for allogenic transfusion, and 1.05 (95% CI = 0.56-1.95; P = .888) for autogenic transfusion. Conclusion Hemophilia is associated with an increased risk of blood transfusion after lower extremity total joint arthroplasty. Patients and providers should discuss these risks before surgery, and insurers should consider incorporating this comorbidity into bundled payments for total hip and knee arthroplasty.

STUDY DESIGN/SETTING This was a retrospective cohort study. PURPOSE The purpose of this study was to examine the association between postoperative cerebrospinal fluid (CSF) leak and anterior cervical discectomy and fusion (ACDF). Specifically, we evaluated: (1) demographic risk factors; (2) comorbid risk factors; (3) indications for surgery; and (4) lengths of stay. SUMMARY OF BACKGROUND DATA CSF leak is a rare but serious complication of ACDF. Currently, there is a paucity of literature describing the risk factors for CSF leak following ACDF. METHODS The Nationwide Inpatient Sample was used to identify all patients who underwent cervical fusion using the anterior approach with excision of intervertebral disc between 1998 and 2010. Patients who had a diagnosis of ossification of the posterior longitudinal ligament in the cervical region were excluded. All patients who had a CSF leak were identified. Demographics and comorbidities were compared via χ analysis, and logistic regression to calculate the odds of having a CSF leak. RESULTS Of the 1,261,140 patients identified, 3048 patients (0.24%) had a postoperative CSF leak. Patients who were between the ages of 55 and 69 years (P=0.038) and 70 years or older (P=0.001) were at an increased risk of CSF leak compared with patients who were aged 40-54 years. Non-white race (P=0.021), obesity, (P

Accelerated discharge protocols for scoliosis surgery have recently been described in the literature. There are limited data describing the association of length of stay (LOS) during the index admission with postoperative outcomes. We sought to define the economic and clinical implications of an additional 1 day in the hospital for scoliosis surgery. The Statewide Planning and Research Cooperative System database was used to identify patients with adolescent idiopathic scoliosis who underwent spinal fusion from 1 October 2007 to 30 September 2012 at high-volume institutions (>20 cases/year) in the state of New York. Regression models were adjusted for age, sex, race, insurance, comorbidity score, and perioperative complications during the index admission. Among the 1286 patients with AIS who underwent spinal fusion, the mean LOS was 4.90 days [95% confidence interval (CI)=4.84-4.97; SD=1.19]. In the perioperative period, 605 (47.05%) underwent transfusion and 202 (15.71%) had problems with pain control. An additional 1 day in the hospital was associated with $11 033 (95% CI=7162-14 904; P

Objective Few have compared short-term outcomes following knee dislocations with or without concomitant popliteal artery disruption (PAD). Methods The Nationwide Inpatient Sample was used to identify 2175 patients admitted for knee dislocation from 2005 to 2013 (concomitant PAD: n = 210/9.7%; without: n = 1965/90.3%). Results Patients with PAD were younger, more often male, Black and Hispanic, and with Medicaid (all p ≤ 0.013). PADs were associated with 11.0-times higher odds of increased LOS (95%CI, 6.6–18.4) and 2.8-times higher odds of experiencing any complication (95%CI, 2.03–3.92). Female sex was a protective factor against increased LOS, (OR = 0.65; 95%CI, 0.48–0.88). Conclusion High suspicion index should be maintained for concomitant vascular injuries following knee dislocations.

Background Smoking is associated with adverse outcomes after total joint arthroplasty (TJA), including periprosthetic joint infection (PJI). Although preoperative smoking cessation interventions may help reduce the risk PJI, the short-term cost-effectiveness of these programs remains unclear. Methods Decision analysis was used to evaluate the cost-effectiveness of a preoperative smoking cessation intervention over a 90-day TJA episode of care. Costs and probabilities were derived from literature review and published Medicare data. Thresholds for cost and efficacy of the intervention were determined using sensitivity analysis. Results In our model, the average 90-day cost was $32 less for patients enrolled in a mandatory smoking cessation intervention ($23,457) compared with patients who were not ($23,489). In sensitivity analyses, the smoking cessation intervention was cost-saving vs no intervention when the short-term cost of PJI was greater than $95,410, the rate of PJI was reduced by at least 25% for former vs current smokers, the cost of the intervention was less than $219, or the success rate of the intervention was greater than 56%. Conclusion Smoking cessation interventions prior to TJA can increase the value of care and are an important public health initiative. Routine referral to smoking cessation interventions should be considered for smokers indicated for TJA. Level of Evidence Level II, economic and decision analyses.

The number of periprosthetic proximal femoral fractures is expected to increase with the increasing prevalence of hip arthroplasties. While native hip fractures have a well-known association with mortality, there are currently limited data on this outcome among the subset of patients with periprosthetic proximal femoral fractures.Using the New York Statewide Planning and Research Cooperative System, we identified patients from 60 to 99 years old who were admitted to a hospital in the state with a periprosthetic proximal femoral fracture (n = 1,655) or a native hip (femoral neck or intertrochanteric) fracture (n = 97,231) between 2006 and 2014. Within the periprosthetic fracture cohort, the indication for the existing implant was not available in the data set. We used mixed-effects regression models to compare mortality at 1 and 6 months and 1 year for periprosthetic compared with native hip fractures.The risk of mortality for patients who sustained a periprosthetic proximal femoral fracture was no different from that for patients who sustained a native hip fracture at 1 month after injury (3.2% versus 4.6%; odds ratio [OR], 0.90; 95% confidence interval [CI], 0.68 to 1.19; p = 0.446), but was lower at 6 months (3.8% versus 6.5%; OR, 0.74; 95% CI, 0.57 to 0.95; p = 0.020) and 1 year (9.7% versus 15.9%; OR, 0.71; 95% CI, 0.60 to 0.85; p0.001). Among periprosthetic proximal femoral fractures, factors associated with a significantly increased risk of mortality at 1 year included advanced age, male sex, and higher Deyo comorbidity scores.In the acute phase, any type of hip fracture appears to confer a similar risk of death. Over the long term, however, periprosthetic proximal femoral fractures are associated with lower mortality rates than native hip fractures, even after accounting for age and comorbidities.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Using the Nationwide Inpatient Sample, we assess the: (1) demographic trends; (2) complications; and (3) length of hospital stay among total knee arthroplasty (TKA) patients with and without human immunodeficiency virus (HIV). The study population consisted of 2772 patients with HIV and 5,672,314 controls. Patients with HIV were more likely to be younger, male, and nonwhite. Patients with HIV were at an increased risk for perioperative wound infections (OR=2.78; P=0.024), although they were not at an increased risk for overall complications (OR=1.21; P=0.321). Mean length of stay was 17% longer for patients with HIV (P0.001). Given these findings, orthopedic surgeons should have a low threshold to work up a patient with HIV for a wound infection following TKA.

Although resident physicians have a critical role in the daily management of patients, based on their limited experiences, they are thought to potentially create inefficiencies in the hospital. With changes set forth by the Comprehensive Care for Joint Replacement (CJR) program, both teaching and non-teaching hospitals are directly compared on efficiency and outcomes. Therefore, the purpose of this study was to compare outcomes between teaching and non-teaching hospitals in the state of New York. Specifically, we compared: (1) duration of stay; (2) cost of admission; (3) disposition; and (4) 90-day readmission for elective primary total knee arthroplasty (TKA).Using the New York Statewide Planning and Research Cooperative System (SPARCS) database, 133,489 patients undergoing primary total knee arthroplasty (TKA) between January 1, 2009 and September 30, 2014 were identified. Outcomes assessed included lengths-of-stay and cost of the index admission, disposition, and 90-day readmission. To compare the above outcomes between the hospital systems, mixed effects regression models were used, which were adjusted for patient demographics, comorbidities, hospital, surgeon, and year of surgery.Patients who underwent surgery at teaching hospitals were found to have longer lengths of stay (b=3.4%, p0.001) and higher costs of admission (b=14.7%; p0.001). Patients were also more likely to be readmitted within 90 days of discharge (OR=1.64; p0.001). No differences were found in discharge disposition status for teaching versus non-teaching hospitals (OR=0.92; p=0.081.The results from this study indicate that at teaching hospitals, a greater number of resources are needed for primary TKA than at non-teaching hospitals. Therefore, teaching hospitals might be inappropriately reimbursed when compensation is linked to competition on economic and clinical metrics. Furthermore, based on this, optimizing reimbursement might inadvertently come at the expense of resident training and education. While some inefficiencies exist as an inherent part of resident training, limiting learning opportunities to optimize compensation can potentially have greater future consequences.

Indications for open reduction and internal fixation (ORIF) of tibia and/or fibula fractures vary; however, some patients require removal of hardware (ROH) due to various complications. Currently, data evaluating the epidemiology of and risk factors for ROH of the tibia/fibula are limited. We examined the associations between tibia/fibula fractures and (1) characteristics of fractures requiring ORIF, (2) indications for ROH, (3) demographic risk factors for ROH; (4) length of stay, and (5) total hospital charges. The Nationwide Inpatient Sample (NIS) was used to identify patients admitted for tibia/fibula ORIF and ROH between 1998 and 2010 in the United States. We used ICD-9 codes to identify fracture locations, comorbidities, and indications for ROH. We identified 1,610,149 ORIF patients, and 56,864 of these patients (3.5%) underwent ROH. Logistic regression analyses and independent sample t-tests were used to assess risk factors and differences. Among fractures requiring ORIF, the most common were for closed fractures of both tibia and fibula. The most common indications for ROH were infection and osteomyelitis. Risk factors for ROH included men and Deyo comorbidity scores of 1 and 2 or more. Age and race were not risk factors for ROH. The length of stay and total charges were significantly higher for ROH compared to those with ORIF only. Hardware removal is a serious complication following ORIF for fractures of the tibia/fibula. The results of the current study suggest that gender, presence of comorbidities, and payer status were all significant factors in predicting hardware removal for the tibia/fibula following ORIF.

Background One of the most important goals of primary total knee arthroplasty (TKA) is to achieve a functional range of motion (ROM). However, up to 20% of patients fail to do so, which can impair activities of daily living.

Robotic and computer navigation technology is available to surgeons for use in hip and knee arthroplasties to increase the precision of component placement. However, they do add significant costs to these procedures, and the long-term clinical outcomes and value of technology assistance for joint replacement remain unclear.We identified 321,522 patients in Medicare Severity Diagnosis Related Groups 469 and 470 who underwent primary total hip arthroplasty (N = 133,472) or primary total or unicompartmental knee arthroplasty (N = 188,050) between 2008 and 2015 in the New York Statewide Planning and Research Cooperative System (SPARCS).Among all total joint arthroplasties performed during this period, technology assistance was used in 5.1% of cases. Technology assistance was more common for knee (7.3%) than hip (1.9%) arthroplasty (P.001). The proportion of cases using technology assistance grew each year, increasing from 2.8% (knee 4.3% and hip 0.5%) in 2008 to 8.6% (knee 11.6% and hip 5.2%) in 2015 (P trend.001). The proportion of hospitals and surgeons using robotic assistance also increased during the study period, increasing from 16.2% of hospitals and 6.2% of surgeons in 2008 to 29.2% of hospitals and 17.1% of surgeons in 2015 (P trend.001 for both). Technology was more likely to be used for patients with private insurance (5.9%) compared with Medicare (4.7%, P.001) or Medicaid (2.2%, P.001), and for patients at high-volume (6.9%, P.001) or very high-volume (6.1%, P.001) as compared with low-volume (2.7%) hospitals.Technology assistance has become increasingly used by orthopedic surgeons for hip and knee arthroplasties, however, adoption has not been uniform.

The Comprehensive Care for Joint Replacement (CJR) model seeks to lower costs and improve quality for primary lower extremity joint replacements. This includes total ankle arthroplasty (TAA), which is performed far less frequently than total hip (THA) and knee (TKA) arthroplasty. We used the SPARCS database to identify 537 TAA and 239,053 elective primary THA or TKA procedures from 2009 to 2014, excluding hip fractures. Compared with THA and TKA, TAA had a shorter mean length of stay (2.2 versus 3.2 days), greater mean cost ($20,817 versus $17,613), lower rate of disposition to nursing and rehabilitation facilities (17% versus 52%), and lower rate of 90-day readmission (4.9% versus 5.8%). In multivariable-adjusted regression models of TAA versus THA and TKA, length of stay was 30% shorter (p .001), costs were 14% greater (p .001), and risk of disposition to nursing and rehabilitation facilities was 86% lower (p .001), with no significant difference in 90-day readmission (p = .957). Patients undergoing TAA had different patterns of short-term resource usage compared with patients undergoing THA and TKA, most notably higher short-term costs. The economic viability of TAA is threatened by alternative payment models that reimburse hospitals for TAA at the same rate as THA and TKA.

As orthopedics transition to value-based purchasing, hospitals and providers are incentivized to identify inefficiencies of care delivery. In our experience, weekends are characterized by decreased staffing of ancillary services to coordinate patient discharges, which can lead to prolonged hospital stays for many of our primary total knee arthroplasty (TKA) admissions.We identified 115,053 patients who underwent primary TKA on a weekday between 2009 and 2013 in New York State. We used mixed effects regression models to compare length of stay (LOS), 90-day readmission, and cost according to the day of TKA.Mean LOS was significantly higher for surgeries performed on Wednesday (P.001), Thursday (P.001), and Friday (P.001). There was no significant difference in 90-day readmission risk according to day of surgery. Mean cost was significantly higher for surgeries performed on Wednesday (P.001), Thursday (P.001), and Friday (P.001). When LOS was held constant across every day of the week, the mean cost of TKA decreased by $247 for Wednesday, $627 for Thursday, and $394 for Friday.Primary TKA performed later in the week is associated with an increased LOS and increased costs of admission, but a similar risk of 90-day readmission. Preferential scheduling of primary TKA cases early in the week, as well as the development of standardized clinical care pathways with appropriate weekend staffing of social work and rehabilitation services, could help to decrease the daily variation in LOS and increase the value of TKA episodes.

Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). Although the number of revision cases is increasing, the prevalence of PJI as an indication for revision surgery, and the variability of this indication among surgeons and hospitals, is unclear.The New York Statewide Planning and Research Cooperative System was used to identify 33,582 patients undergoing revision THA between 2000 and 2013. PJI was identified using International Classification of Diseases, Ninth Revision diagnosis codes. Volume was defined using mean number of revision THAs performed annually by each hospital and surgeon.PJI was the indication for 13.0% of all revision THAs. The percentage of revision THAs for PJI increased between years 2000 and 2007 (odds ratio [OR] = 1.05, P.001), but decreased between years 2008 and 2013 (OR = 0.96, P = .001). Compared to medium-volume hospitals, the PJI burden at high-volume hospitals decreased during years 2000-2007 (OR = 0.58, P.001) and 2008-2013 (OR = 0.57, P.001). Compared to medium-volume surgeons, the PJI burden for high-volume surgeons increased during years 2000-2007 (OR = 1.39, P.001), but did not differ during years 2008-2013 (P = .618).The burden of PJI as an indication for revision THA may be plateauing. High-volume institutions have seen decreases in the percentage of revisions performed for PJI over the complete study duration. Specific surgeon may be associated with the plateauing in PJI rates as high-volume surgeons in 2008-2013 were no longer found to be at increased risk of PJI as an indication for revision THA.

Although resident physicians play a vital role in the US health care system, they are believed to create inefficiencies in the delivery of care. Under the regional component of the Comprehensive Care for Joint Replacement model, teaching hospitals are forced to compete on efficiency and outcomes with nonteaching hospitals.We identified 86,021 patients undergoing elective primary total hip arthroplasty in New York State between January 1, 2009, and September 30, 2014. Outcomes included length and cost of the index admission, disposition, and 90-day readmission. Mixed-effects regression models compared teaching vs nonteaching orthopedic hospitals after adjusting for patient demographics, comorbidities, hospital, surgeon, and year of surgery.Patients undergoing surgery at teaching hospitals had longer lengths of stay (β = 3.2%; P.001) and higher costs of admission (β = 13.6%; P.001). There were no differences in disposition status (odds ratio = 1.03; P = .779). The risk of 90-day readmission was lower for teaching hospitals (odds ratio = 0.89; P = .001).Primary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission. This suggests that teaching hospitals may be adversely affected by reimbursement tied to competition on economic and clinical metrics. Although a certain level of inefficiency is inherent during the learning process, these policies may hinder learning opportunities for residents in the clinical setting.

Total shoulder arthroplasty (TSA) has become a popular and successful surgery to treat advanced glenohumeral arthritis, rotator cuff arthropathy, and proximal humerus fractures. Historical data is available investigating the epidemiology of total shoulder arthroplasty with regard to patient characteristics, outcomes, and complications; however, there is a lack of studies investigating the most recent and up to date national trends related to shoulder replacement. The purpose of this study was to evaluate changes in the annual incidence, various demographics, and complications of TSA in America.The Nationwide Inpatient Sample (NIS) was assessed to identify all patients who were admitted for TSA in the United States between 1998 and 2010. National trends in patient demographics, incidence, and length-of-stay (LOS) were analyzed for correlations. The impacts of contributing factors to each outcome were assessed using adjusted multivariable regression analysis. These were used to calculate odds ratios of cohort demographics and their association with complications and LOS.Admissions for TSA have risen (8,041 to 39,072 admissions). The majority of the cohort consisted of Caucasian men between the ages of 64 and 79 years. The incidence rate of complications has remained consistent. Female gender, age80 years, and higher Deyo Comorbidity scores were risk factors for higher complications. The LOS has decreased (2.96 to 2.21 days) during the study time period. Female gender, African-American race, Medicaid insurance, and higher Deyo Comorbidity scores were associated with longer stays.Our study demonstrates a rapid increase in incidence rates of TSAs within the 13-year period in the United States. An increased risk of complications was noted with older age, female gender, and increased Deyo score.Our findings may help health care providers identify ways to better manage this procedure and select patients.

Background and Aims Data regarding smoking and alcohol consumption and risk of gastrointestinal bleeding (GIB) are sparse and conflicting. We assessed the risk of major GIB associated with smoking and alcohol consumption in a large, prospective cohort. Methods We prospectively studied 48,000 men in the Health Professional follow-up Study (HPFS) who were aged 40–75 years at baseline in 1986. We identified men with major GIB requiring hospitalization and/or blood transfusion via biennial questionnaires and chart review. Results We documented 305 episodes of major GIB during 26 years of follow-up. Men who consumed >30 g/day of alcohol had a multivariable relative risk (RR) of 1.43 (95% confidence interval (CI), 0.88–2.35; P for trend 0.006) for major GIB when compared with nondrinkers. Alcohol consumption appeared to be primarily related to upper GIB (multivariable RR for >30 g/day vs. nondrinkers was 1.35; 95% CI, 0.66–2.77; P for trend 0.02). Men who consumed ≥ 5 drinks/week vs. < 1 drink/month of liquor had a multivariable RR of 1.72 (95% CI, 1.26–2.35, P for trend

Background: With recent advances in the treatment of infection with hepatitis C increasing lifespan and quality of life, the need for total joint arthroplasty in this patient population is expected to grow. Presently, there are limited and conflicting data on the perioperative outcomes of lower-extremity total joint arthroplasty among patients with hepatitis C. The purpose of our study was to assess the association between hepatitis C and perioperative outcomes of lower-extremity total joint arthroplasty. Methods: The Nationwide Inpatient Sample database was used to identify patients who underwent a total hip or knee arthroplasty in the United States from 1998 to 2010. Controls were matched in a three-to-one ratio to patients with hepatitis-C infection according to surgical procedure, age, race, sex, Deyo comorbidity score, and year of surgical procedure. Outcomes included perioperative complications (any, medical, surgical) and mean length of stay. Results: There were 1,700,400 total joint arthroplasties performed and recorded in the database during the study period, among which 8044 patients (0.47%) had a documented hepatitis-C infection. The frequency of hepatitis-C infection increased from 1.9 per 1000 total joint arthroplasties in 1998 to 5.9 per 1000 total joint arthroplasties in 2010 (slope = 0.47; r2 = 0.93). Compared with matched controls, patients with hepatitis C had a 30% increased risk of any complication (95% confidence interval, 17% to 44%; p < 0.001), a 15% increased risk of a medical complication (95% confidence interval, 2% to 30%; p = 0.025), a 78% increased risk of a surgical complication (95% confidence interval, 49% to 112%; p < 0.001), and a mean length of stay that was 14% longer (95% confidence interval, 12% to 15%; p < 0.001). Conclusions: Infection with hepatitis C is an infrequent but increasingly common comorbidity among patients undergoing total joint arthroplasty. Given these findings, orthopaedic surgeons should be aware of the increased risks of total joint arthroplasty in patients with hepatitis C and should discuss these risks with potential surgical candidates during a shared decision-making process. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Systemic corticosteroids are commonly used to treat autoimmune and inflammatory diseases, but they can be associated with various musculoskeletal problems and disorders. There currently is a limited amount of data describing the postoperative complications of THA associated specifically with chronic corticosteroid use.For chronic corticosteroid users undergoing THA, we asked: (1) What is the risk of hospital readmission at 30 and 90 days after surgery? (2) What is the risk of venous thromboembolism at 30 and 90 days after surgery? (3) What is the risk of revision hip arthroplasty at 12 and 24 months after surgery?We identified patients in the Statewide Planning and Research Cooperative System who underwent primary THA between January 2003 and December 2010. This database provides hospital discharge abstracts for all admissions in the state of New York each year. We used propensity scores to three-to-one match the 402 chronic corticosteroid users with a comparison cohort of 1206 patients according to age, sex, race, comorbidity score, year of surgery, and hip osteonecrosis. The risk of each outcome was compared between chronic corticosteroid users and the matched cohort. Because multiple comparisons were made, we considered p less than 0.008 as statistically significant.Readmission was more common for corticosteroid users at 30 days (odds ratio [OR], 1.45; 95% CI, 1.14-1.85; p = 0.003) and 90 days (OR, 1.37; 95% CI, 1.09-1.73; p = 0.007). Venous thromboembolism was not more frequent in corticosteroid users at 30 days (OR, 2.39; 95% CI, 1.08-5.26; p = 0.031) or 90 days (OR, 1.91; 95% CI, 1.03-3.53; p = 0.039). Revision arthroplasty was more common in corticosteroid users at 12 months (OR, 2.49; 95% CI, 1.35-4.59; p = 0.004), but not 24 months (OR, 2.04; 95% CI, 1.19-3.50; p = 0.010).After THA, chronic corticosteroid use is associated with an increased risk of readmission at 30 and 90 days and revision hip arthroplasty at 12 months in corticosteroid users. Patients and providers should discuss these risks before surgery. Insurers should consider incorporating chronic corticosteroid use as a comorbidity in bundled payments for THA, since this patient population is more likely to return to their provider for care during the postoperative period.Level III, therapeutic study.

Reduced hospital staffing on weekends is a hypothesized risk factor for adverse health outcomes--commonly referred to as the weekend effect. We conducted a study on the effect of weekend admission on short-term outcomes among US hip fracture patients. We selected Nationwide Inpatient Sample (1998-2010) patients with a principal diagnosis of femoral neck fracture and grouped them by day of admission (weekend or weekday). We used multivariate logistic and linear regression analyses, controlling for age, race, sex, number of comorbidities, and other risk factors, to calculate odds ratios (ORs) of mortality and perioperative complications as well as mean difference in length of hospital stay. Our study population included 96,892 weekend and 248,097 weekday admissions. Compared with patients admitted on weekdays, patients admitted on weekends had lower mortality (OR, 0.94; 95% confidence interval [CI], 0.89-0.99) and shorter mean hospital stay (estimate, 3.74%; 95% CI, 3.40-4.08) but did not differ in risk of perioperative complications (OR, 1.00; 95% CI, 0.98-1.02). Weekend admission did not predict death, perioperative complications, longer hospital stay, or other adverse short-term outcomes. Our study data do not support a weekend effect among hip fracture admissions in the United States.

Open fracture is a serious orthopaedic injury that can lead to significant patient morbidity and mortality. There is limited data on the mortality risk for open compared to closed long bone fracture.The Nationwide Inpatient Sample was used to identify all patients who were admitted with a long bone fracture in the United States between 1998 and 2010. Cox proportional hazards regression modeling was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) of mortality.After adjusting for age, gender, race, insurance, and comorbidities, the HR of mortality was 2.89 (95% CI, 2.56-3.28; p0.001) for open compared to closed fracture. Stratified by anatomical site, the HR of mortality for open compared to fracture was 3.43 for femur (95% CI, 2.78-4.23; p0.001), 2.81 for tibia or fibula (95% CI, 2.17-3.64; p0.001), 2.54 for humerus (95% CI, 1.81-3.56; p0.001), and 1.56 for radius or ulna (95% CI, 1.10-2.23; p=0.014).This data suggests that open fracture carries a worse prognosis compared to closed fracture at the same anatomical site.

With recent increases in life expectancy in the United States, the number of nonagenarians (age 90-99 years) presenting for lower extremity joint arthroplasty (TJA) will likely rise. Utilizing the National Surgical Quality Improvement Program database, we compared 30-day outcomes of TJA between nonagenarians and controls (age

This study evaluated inpatient cruciate ligament reconstruction in the United States during a 13-year period. The Nationwide Inpatient Sample database was used to identify inpatient cruciate ligament reconstructions performed from 1998 to 2010. National trends in incidence, patient demographics, perioperative complications, length of stay, and total admission costs were evaluated. The impact of various contributing factors on these outcomes was further evaluated using multivariable regression analyses. The rate of inpatient cruciate ligament reconstruction has decreased significantly in the United States during the past decade. The outcome data from this study can be used as a comparison cohort for future outpatient analyses of anterior cruciate ligament reconstruction in the United States. [ Orthopedics. 2016; 39(1):e196–e202.]

Introduction With each passing year, the number of patients with end-stage renal disease (ESRD) is increasing steadily, but there are limited data on the postoperative outcomes of these patients after appendectomy. Methods Using the Nationwide Inpatient Sample, we identified all patients who underwent appendectomy in the United States between 1998 and 2010. We used International Classification of Diseases, 9th Revision, Clinical Modification codes to identify patients with ESRD and to track postoperative complications during hospital admission. Statistical models were controlled for age, sex, race, insurance type, number of Elixhauser comorbidities, year of admission, perforation of the appendix, and operative approach. Results The study population included 5,712 patients with ESRD, with the remaining 3,615,391 patients serving as reference controls. Patients with ESRD had risk of death that was nearly 5 times greater than controls (odds ratio [OR] 5.68; 95% confidence interval [95% CI] 3.96–8.15; P

Recent studies have shown successful midterm outcomes after total hip arthroplasty (THA) in patients with human immunodeficiency virus (HIV). However, little data exist on the epidemiology, risk of perioperative complications, and length of stay in patients with HIV receiving THA.The purposes of this study were to assess (1) the demographic trends of patients with HIV who underwent primary THA; (2) the differences in the risk of major and minor perioperative complications among patients with and without HIV; and (3) the differences in mean length of hospital stay among patients with and without HIV.The Nationwide Inpatient Sample was used to compare patients with and without HIV who were admitted for THA between 1998 and 2010 in the United States. We extracted data on each admission's age, sex, race, insurance, and comorbidities. The study population consisted of 2,656,696 patients without HIV and 9275 patients with HIV.Patients with HIV were more likely to be younger, be male, not pay with Medicare, and be of a nonwhite race. After controlling for confounding variables, patients with HIV were more likely to have major complications (2.9% [266 of 9275] versus 2.7% [71,952 of 2,656,696]; odds ratio [OR], 1.47; 95% confidence interval [CI], 1.08-2.00; p=0.014) and minor complications (5.2% [483 of 9275] versus 4.8% [127,940 of 2,656,696]; OR, 1.61; 95% CI, 1.29-2.02; p0.001) compared with patients who did not have HIV. Patients undergoing THA who had HIV also had an increased length of hospital stay compared with patients without HIV (4.31 versus 3.83 days, p0.001).Given these findings, we believe orthopaedic surgeons should be aware of the potential for longer and more complicated hospital stays after THA among patients with HIV. However, the modest increase in risk of adverse outcomes does not cause us to recommend against THA for patients with HIV who otherwise meet reasonable surgical indications. Future studies should explore the relationships between markers of HIV severity and risk of adverse outcomes after THA during the hospital stay and followup.Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Although the composition of the human microbiome is now well-studied, the microbiota’s >8 million genes and their regulation remain largely uncharacterized. This knowledge gap is in part because of the difficulty of acquiring large numbers of samples amenable to functional studies of the microbiota. We conducted what is, to our knowledge, one of the first human microbiome studies in a well-phenotyped prospective cohort incorporating taxonomic, metagenomic, and metatranscriptomic profiling at multiple body sites using self-collected samples. Stool and saliva were provided by eight healthy subjects, with the former preserved by three different methods (freezing, ethanol, and RNAlater) to validate self-collection. Within-subject microbial species, gene, and transcript abundances were highly concordant across sampling methods, with only a small fraction of transcripts (

Background & Aims Obesity is associated with systemic inflammation, alterations in the intestinal microbiome, and decreased epithelial integrity. The association between obesity and peptic ulcer has not been investigated thoroughly. Methods We conducted a prospective cohort study of 47,120 men enrolled in the Health Professionals Follow-Up Study (mean age at baseline, 54 y). Biennially, we updated information on body mass index (BMI), physical activity, smoking, and use of nonsteroidal anti-inflammatory drugs or aspirin. Self-reported waist and hip measurements were validated among a subsample of participants. Self-reported cases of gastric and duodenal ulcers were confirmed by medical record review. Helicobacter pylori status was determined from endoscopic biopsy specimens, serum antibody measurements, and/or stool antigen assays documented in the medical record. We used Cox proportional hazards modeling to calculate hazard ratios and 95% confidence intervals (CIs). Results We documented 272 gastric and 320 duodenal ulcers over 24 years of follow-up evaluation. The multivariate-adjusted hazard ratio for gastric ulcer was 1.83 (95% CI, 1.20–2.78; P trend 2 ), compared with men with BMIs of 23.0 to 24.9 kg/m 2 , and 1.88 (95% CI, 1.06–3.33; P trend = .04) for men with waist-to-hip ratios (WHR) of 1.00 or higher, compared with men with a WHR of 0.85 to 0.89. The risk of duodenal ulcer was not associated with BMI ( P trend = .24) or WHR ( P trend = .68). In secondary analyses, increased BMI and WHR each were associated with increased risk of H pylori –negative, but not H pylori –positive, ulcers. The effect of BMI on ulcer risk did not change with use of aspirin or nonsteroidal anti-inflammatory drugs, alcohol consumption, physical activity, or smoking. Conclusions In a large prospective cohort of male health professionals, central and total obesity were associated with increased risk of peptic ulcer—particularly gastric and H pylori –negative ulcers.

There are several periprosthetic complications associated with total knee arthroplasty, with femoral fracture as the most common and patellar fractures as the second most common. Patellar fractures are challenging complications that occur almost exclusively on the resurfaced patellae, although unresurfaced patellar fractures have been reported in literature. The purpose of this study is to describe the anatomy of the patella, the etiology of patellar fractures, and strategies to treat and manage these fractures following knee arthroplasty. The vascular supply to the patella may be compromised during total knee arthroplasty and special care must be taken to preserve it. Vessel injury may result in further complications, most notably avascular necrosis with subsequent fracture. Other patient-, surgical-, and prosthetic-related factors can contribute to increased risk of patellar fracture. Patellar fractures are classified into three types. Type I fractures have an intact extensor mechanism with a stable implant. Type II fractures have a complete disruption of the extensor mechanism with or without a stable implant. Type III fractures, which are further subclassified into types IIIa and IIIb, have an intact extensor mechanism but a loose patellar component. While type IIIa fractures have reasonable remaining bone stock, type IIIb fractures have poor bone stock. Type I patellar fractures may be best managed nonoperatively, but types II and III patellar fractures often necessitate surgical intervention. Patellectomy should be reserved for comminuted fractures, as well as fractures in patients with poor bone stock. Larger prospective randomized studies are necessary to better evaluate the treatment algorithm for patellar fractures following total knee arthroplasty.

G A A b st ra ct s significant differences in adenoma detection at follow up. Methods: Data were collected prospectively in a randomized placebo controlled chemoprevention trial (Vitamin D/Calcium) from May 2004 to Nov 2008. Subjects (45-75 yrs) had at least 1 colorectal adenoma removed and none remaining after complete colonoscopy. Trial eligibility required that subjects have either 3 yr or 5 yr follow up, as determined by the endoscopist at the qualifying exam. Subjects with 1 to 2 small non-advanced adenomas on baseline were included. Data collected included patient (age, gender, race/ethnicity, family history, BMI, smoking, study center), baseline endoscopist (age, gender, specialty), and baseline and follow up exam findings. Comparisons were made between subjects with recommended follow-up of 3 vs 5 yrs. A t-test was used to compare continuous variables while Chi Square was used to compare proportions or categorical data. We fit a generalized linear model to evaluate predictors of 3 vs. 5 yr surveillance interval. We also used generalized linear models to compute risk ratios for outcome findings at the follow up exam (e.g. adenoma, advanced adenoma) comparing the recommended 5 to 3 yr intervals. Results: Of the 2259 enrolled subjects, 1560 had LRAs on baseline colonoscopy and had a follow up exam during the trial. 38.1 % (n=594) of the subjects had a 3 yr recommended follow up interval. There were no differences between the groups with regards to subject age, gender, smoking, activity level, BMI, ETOH, bowel prep, endoscopist age or gender. After adjustment for subject age, gender and clinical center, significant factors contributing to exams being recommended at a 3 vs a 5 yr interval were family history of CRC, having 2 adenomas on baseline, and having serrated lesions at baseline (Table 1). There were no significant differences in exam findings on follow up for the 3 vs 5 yr group (Table 2). Conclusions: Endoscopists frequently recommend shorter intervals for LRAs than those recommended by guidelines. Both clinical and endoscopic factors such as family history and the number of serrated lesions found appear to influence the decision making process. However neoplasia detection was similar between the two groups and thus the results support current surveillance guidelines that recommend follow up intervals of at least 5 yrs for LRAs. Table 1. Factors contributing to exam being recommended at a shorter interval (3 versus 5 years)

Background: The existing literature regarding smoking and alcohol consumption and risk of gastrointestinal bleeding (GIB) is sparse and conflicting. In an attempt to study modifiable risk factors of GIB, we assessed the risk of GIB associated with smoking and alcohol consumption in a large prospective cohort of men. Methods: We studied 51,529 men in the Health Professional follow-up Study (HPFS) who were aged 40-75 years at baseline in 1986. We identified men with GIB requiring hospitalization and/or blood transfusion based on their responses to biennial questionnaires from 2006-2012 and reviewed medical records to validate self-report. Information about smoking and alcohol consumption was updated every two and four years, respectively. We used Cox proportional hazards regression to calculate the relative risks (RR) and 95% confidence intervals (CI) adjusting for age, study year, body mass index, physical activity, regular aspirin and nonsteroidal anti-inflammatory drug use, and alcohol/smoking. Results: We documented 311 episodes of GIB during a 26-year follow up period. After adjustments for other potential risk factors, individuals who consumed >15 g/day of alcohol had a multivariate RR of 1.65 (95% CI, 1.10-2.47; p for linear trend 0.004) when compared with men who did not consume alcohol. Intake of > 15 g/day of alcohol appeared to be primarily related to upper GIB (multivariable RR 1.74; 95% CI, 0.98-3.08; p for linear trend 0.007). Risk of GIB increased linearly with amount of liquor consumed (p for linear trend 15 g/day of alcohol was significantly associated with peptic ulcer disease (multivariable RR 1.85; 95% CI, 0.97-3.54; p for linear trend 0.02), but not esophagitis/gastritis/duodentitis, or diverticular bleeding. There were few cases of bleeding due to portal hypertension (n=4). Current and past smokers did not appear to have increased risk of GIB when compared to those who never smoked (multivariable RR 0.89; 95% CI, 0.45-1.76 and 1.12, 95% CI 0.88-1.41, respectively). We also did not find a significant association between pack years of smoking and risk of GIB (multivariable RR 1.01; 95% CI, 0.63-1.62 when comparing men with at least 45 pack-years of exposure to never smokers). Conclusions: In this large prospective study, alcohol consumption, but not smoking, was associated with an increased risk of GIB. Associations were most notable for upper GI bleeding associated with intake of liquor.

G A A b st ra ct s Cytokine Signalling (SOCS) 1 and 3 determined by quantitative real-time PCR. Results IFNβ was detected in the lamina propria of both control and IBD tissue and ISGs (MXA and 250AS) were expressed by intestinal T cells sorted from tissue. In vitro, IFNβ neutralisation reduced the frequency of pSTAT1+ intestinal T cells (n=6, p=0.05) and, in healthy controls, decreased the proportion of IL10-producing intestinal T cells (n=8, p=0.01). There was a trend for more IFNγ-producers (p=0.059) and IFNγ concentrations in supernatants were significantly increased (n=10, p=0.016). In IBD, intestinal T cells were more responsive to IFNβ in vitro, as assessed by ISG induction, (n=10 for patients and controls, p

OBJECTIVES: Periodontal disease has been associated with higher circulating levels of inflammatory markers and conditions associated with chronic inflammation, including vascular disease, diabetes mellitus, and cancer. Limited data exist on the relationship between periodontal disease and gastric and duodenal ulcer. METHODS: We conducted a prospective cohort study of 49,120 men in the Health Professionals Follow-up Study, aged 40–75 years at enrollment in 1986. Biennially, we assessed periodontal disease, tooth loss, and other risk factors for gastric and duodenal ulcer. We validated diagnoses of gastric and duodenal ulcer through medical record review. We used Cox proportional hazards modeling, adjusting for potential confounders, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: We documented 138 cases of gastric ulcer and 124 cases of duodenal ulcer with available information on Helicobacter pylori status over 24 years of follow-up. After adjustment for risk factors, including smoking and regular use of aspirin and non-steroidal anti-inflammatory drugs, men with periodontal disease with bone loss had a multivariate HR of ulcer of 1.62 (95% CI, 1.24–2.12). Periodontal disease appeared to be associated with a similar risk of developing ulcers that were H. pylori negative (HR 1.75; 95% CI, 1.26–2.43) than H. pylori positive (HR 1.40; 95% CI, 0.87-2.24), as well as ulcers in the stomach (HR 1.75; 95% CI, 1.21–2.53) than ulcers in the duodenum (HR 1.47; 95% CI, 0.98–2.19). CONCLUSIONS: Periodontal disease is associated with an increased risk of incident gastric and duodenal ulcer. This relationship may be mediated by alterations in the oral and gastrointestinal microbiome and/or systemic inflammatory factors.