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      What are the incidence and risk factors of in-hospital mortality after venous thromboembolism events in total hip and knee arthroplasty patients?

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          Abstract

          Background

          Pulmonary embolism and deep vein thrombosis, together referred to as venous thromboembolism (VTE), are serious and potentially preventable complications after total hip arthroplasty and total knee arthroplasty. The aim of this study was to investigate the incidence of mortality after VTE events and assess the risk factors that are associated with it.

          Methods

          The Nationwide Inpatient Sample was used to estimate the total number of total hip arthroplasty, total knee arthroplasty, VTE events, and mortality using the International Classification of Diseases, Ninth Revision procedure codes from 2003 to 2012. Patients' demographics, Elixhauser, and Charlson comorbidity indices were used to identify the risk factors associated with in-hospital VTEs and mortality.

          Results

          A total of 1,805,621 THAs and TKAs were included. The overall rate of VTE was 0.93%. The in-hospital mortality rate among patients with VTEs was 7.1% vs 0.30% in patients without VTEs ( P-value < .0001). The risk factors for mortality after VTE events in descending order were as follows: hypercoagulable state (odds ratio [OR]: 5.3, 95% confidence interval [CI]: 3.6-5.8), metastatic cancer (OR: 5.2, 95% CI: 3.3-5.6), myocardial infarction (OR: 4.2, 95% CI: 2.3-4.7), peripheral vascular disease (OR: 3.6, 95% CI: 3.2-4.0), cardiac arrhythmias (OR: 3.2, 95% CI: 1.6-4.3), advanced age (OR: 3.1, 95% CI: 2.3-3.7), electrolyte disorders (OR: 3.1, 95% CI: 2.2-3.6), pulmonary circulation disorders (OR: 2.9, 95% CI: 2.6-3.3), depression (OR: 2.8, 95% CI: 1.6-3.4), complicated diabetes (OR: 2.7, 95% CI: 2.1-3.2), weight loss (OR: 2.6, 95% CI: 2.2-3.3), renal failure (OR: 2.6, 95% CI: 1.7-3.5), chronic pulmonary disease (OR: 2.5, 95% CI: 1.3-3.1), valvular disease (OR: 2.4, 95% CI: 1.8-2.7), liver disease (OR: 1.7, 95% CI: 1.2-1.9), and obesity (OR: 1.6, 95% CI: 1.5-1.9).

          Conclusions

          In-hospital VTE has a significant in-hospital mortality rate. Several of the identified risk factors in this study are modifiable preoperatively. We strongly urge the orthopaedic community to be cognizant of these risk factors and emphasize on optimizing patients' comorbidities before an elective arthroplasty.

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          Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.

          Chunliu Zhan, Marlene Miller (2003)
          Although medical injuries are recognized as a major hazard in the health care system, little is known about their impact. To assess excess length of stay, charges, and deaths attributable to medical injuries during hospitalization. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) were used to identify medical injuries in 7.45 million hospital discharge abstracts from 994 acute-care hospitals across 28 states in 2000 in the AHRQ Healthcare Cost and Utilization Project Nationwide Inpatient Sample database. Length of stay, charges, and mortality that were recorded in hospital discharge abstracts and were attributable to medical injuries according to 18 PSIs. Excess length of stay attributable to medical injuries ranged from 0 days for injury to a neonate to 10.89 days for postoperative sepsis, excess charges ranged from 0 dollar for obstetric trauma (without vaginal instrumentation) to 57 727 dollars for postoperative sepsis, and excess mortality ranged from 0% for obstetric trauma to 21.96% for postoperative sepsis (P<.001). Following postoperative sepsis, the second most serious event was postoperative wound dehiscence, with 9.42 extra days in the hospital, 40 323 dollars in excess charges, and 9.63% attributable mortality. Infection due to medical care was associated with 9.58 extra days, 38 656 dollars in excess charges, and 4.31% attributable mortality. Some injuries incurred during hospitalization pose a significant threat to patients and costs to society, but the impact of such injury is highly variable.
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            Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review.

            Jean-Marie Januel, Christiane Ruffieux, Hude Quan … (2012)
            Symptomatic venous thromboembolism (VTE) after total or partial knee arthroplasty (TPKA) and after total or partial hip arthroplasty (TPHA) are proposed patient safety indicators, but its incidence prior to discharge is not defined. To establish a literature-based estimate of symptomatic VTE event rates prior to hospital discharge in patients undergoing TPHA or TPKA. Search of MEDLINE, EMBASE, and the Cochrane Library (1996 to 2011), supplemented by relevant articles. Reports of incidence of symptomatic postoperative pulmonary embolism or deep vein thrombosis (DVT) before hospital discharge in patients who received VTE prophylaxis with either a low-molecular-weight heparin or a subcutaneous factor Xa inhibitor or oral direct inhibitor of factors Xa or IIa. Meta-analysis of randomized clinical trials and observational studies that reported rates of postoperative symptomatic VTE in patients who received recommended VTE prophylaxis after undergoing TPHA or TPKA. Data were independently extracted by 2 analysts, and pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-effects models. The analysis included 44,844 cases provided by 47 studies. The pooled rates of symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%) for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA. The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14% (95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in TPHA studies. Using current VTE prophylaxis, approximately 1 in 100 patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops symptomatic VTE prior to hospital discharge.
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              Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study.

              James A Browne, Benjamin Sandberg, Michele D'Apuzzo … (2014)
              The purpose of this study was to assess the incidence of the diagnosis of depression and determine the impact of this diagnosis on early postoperative outcomes following total joint arthroplasty (TJA). Multivariate analysis of the Nationwide Inpatient Sample database was used to compare the association of depression with inhospital morbidity, mortality, length of stay, and hospital charges following TJA. The rate of diagnosis of depression in the arthroplasty population was 10.0%. Patients with depression were significantly more likely to be white, female, and have Medicaid as a primary payer (all P<0.05). Depression was associated with a greater risk of post-operative psychosis (OR = 1.74), anemia (OR = 1.14), infection (OR = 1.33), and pulmonary embolism (OR 1.20), and a lower risk of cardiac (OR = 0.93) and gastrointestinal complications (OR = 0.80). Depression was not associated with in-hospital mortality. Depression appears to impact early postoperative morbidity after TJA, a finding which is important for patient counseling and risk adjustment.
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                Author and article information

                Contributors
                Alisina Shahi
                Journal
                Journal ID (nlm-ta): Arthroplast Today
                Journal ID (iso-abbrev): Arthroplast Today
                Title: Arthroplasty Today
                Publisher: Elsevier
                ISSN (Electronic): 2352-3441
                Publication date PMC-release: 26 May 2018
                Publication date Collection: September 2018
                Publication date (Electronic): 26 May 2018
                Volume: 4
                Issue: 3
                Pages: 343-347
                Affiliations
                [a ]Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
                [b ]Orthopaedic Department, Emory University School of Medicine, Atlanta, GA, USA
                [c ]Orthopaedic Department, Med Care Hospital, Dubai, UAE
                [d ]Orthopaedic Department, University of Alabama, Birmingham, AL, USA
                [e ]Oliashirazi Institute at Marshall Orthopaedics, Marshall University, Huntington, WV, USA
                Author notes
                [∗ ]Corresponding author. 125 s 9th Street, Sheridan Bld. Ste 10000, Philadelphia, PA 19107, USA. Tel.: +1 484 904 5799. alisinair@ 123456gmail.com
                Article
                Publisher ID: S2352-3441(18)30038-4
                DOI: 10.1016/j.artd.2018.02.014
                PMC ID: 6123180
                PubMed ID: 30186919
                SO-VID: e3f235b2-a545-4ebf-bfc2-b14267924a49
                Copyright © © 2018 The Authors
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 30 November 2017
                Date revision received : 25 February 2018
                Date accepted : 28 February 2018
                Categories
                Subject: Original Research

                Keywords: venous thromboembolism,mortality,incidence,risk factors,total hip arthroplasty,total knee arthroplasty
                Data availability:
                Keywords: venous thromboembolism, mortality, incidence, risk factors, total hip arthroplasty, total knee arthroplasty

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