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Mental health conditions cited as strong predictor for post TJA complications
Accurate risk adjustment tools may help compare patients in the total joint population.
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Among patients undergoing total joint arthroplasty, mental health conditions demonstrated a strong predictive effect for serious postoperative complications and should be included in a risk-adjustment tool, according to researchers of a recently published study.
“Although mental illness has been associated with poorer health status and treatment outcomes in the past, the magnitude of its contribution to complications and readmissions is dramatic and creates the opportunity for improving the care for patients at high risk when they undergo orthopedic procedures,” study co-author Courtland Lewis, MD, of Orthopedic Associates of Hartford in Farmington, Conn., told Orthopedics Today.
Postoperative complications
Using the hospital-based Connecticut Joint Replacement Institute registry, Lewis and his colleagues collected demographic data, and information on preoperative comorbidities, intraoperative surgical measures, length of hospital stay, postoperative complications and 30-day readmissions among 5,314 patients who underwent either total hip or knee arthroplasty at a single institution from October 2008 through September 2011.
Primary study endpoints included the incidence of reoperation during same admission; length of stay longer than 4 days; readmission within 30 days post-surgery and the incidence of postoperative orthopedic, major non-orthopedic or minor non-orthopedic complications.
The researchers discovered the overall incidence of the primary endpoints was 3.8%. Patients with pre-existing psychiatric conditions, including delirium, dementia or depressive psychosis, had the highest risk ratios predictive of postoperative complications and extended lengths of hospital stay. The relative risk of orthopedic postoperative complications in patients with these conditions was 3.1. Having a pre-existing psychiatric condition showed relative risks of 4.7 for both major and minor non-orthopedic complications. The relative risk of a longer hospital stay was 12 for these patients, according to the study.
The researchers found a history of venous thromboembolism was a significant predictor for postoperative major non-orthopedic complications. Genitourinary conditions were also significant predictors for postoperative complications.
Prolonged operating time was a significant predictor for extended length of stay, readmissions and complications when analyzed as a continuous variable, according to the researchers.
“Most importantly, we are able to predict who among arthroplasty patients is at risk for complications and focus our attention on this subset pre- and peri-operatively. In the future, we should be able to apply principles of care management to this group and, hopefully, improve their outcomes,” Lewis said. “Secondarily, at a time when we as surgeons — and hospitals — are being evaluated around complications and readmissions, it is imperative that our patients be accurately risk stratified to ensure fair comparisons. Risk adjustment ‘tools’ currently being used may not be sensitive enough to accurately portray these differences in total joint patient populations among surgeons and hospitals.”
Future research
According to Lewis, the next step in their research will focus on validating their data by expanding it from a single institution to a broad spectrum of patients. Currently, the American Association of Hip & Knee Surgery is working with Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR), among others, in developing a predictive model for risk adjustment. Lewis and his colleagues on this study will be collaborators.
“Ultimately, our goal is to study the impact of preoperative intervention in at-risk patients in an effort to lower their risk of complication and improve their surgical outcomes,” Lewis said. – by Casey Tingle
Reference:
Inneh IA. J Arthroplasty. 2014;doi:10.1016/j.arth.2014.05.007.
For more information:
Courtland Lewis, MD, can be reached at Orthopedic Associates of Hartford, Farmington, Conn.; email: courtlandlewis@hotmail.com.
Disclosure: Lewis has no relevant financial disclosures.