Key result
Having ≥2 preoperative medical predictors identifies ~56% of preventable post-arthroplasty complications.
Why the study?
Does a simple preoperative risk score (≥2 MPEH predictors) identify patients at high risk of potentially preventable medical and surgical complications in fast-track total hip and knee arthroplasty?
Cohort (n=8,737)
Yes
Does a simple preoperative risk score (≥2 MPEH predictors) identify patients at high risk of potentially preventable medical and surgical complications in fast-track total hip and knee arthroplasty?
Preoperative risk stratification in fast-track hip and knee arthroplasty can statistically identify patients at higher risk for preventable medical (including cardiac arrhythmias and pneumonia) but not surgical complications, though clinical utility is limited by a high number needed to treat.
Answers are grounded in this paper and cite their sources.
May support targeted optimization in high-risk fast-track arthroplasty; leaves open whether risk stratification improves outcomes in prospective studies.
OBJECTIVES: Construction of a simple preoperative risk score for patients in high risk of potentially preventable 'medical' complications. Secondary objectives were to construct simple preoperative risk scores for 'severe medical', 'surgical' and 'total' potentially preventable complications. DESIGN: Prospective observational study. SETTING: Elective primary unilateral total hip and knee arthroplasty with prospectively collected preoperative patient characteristics; similar standardised fast-track protocols; evaluation of complications through discharge and medical records; and complete 90 days follow-up through nationwide databases. PARTICIPANTS: 8373 consecutive unselected total hip arthroplasty (THA) and knee arthroplasty from January 2010 to November 2012. RESULTS: There were 557 procedures (6.4%) followed by potentially preventable complications resulting in hospitalisation >4 days or readmission. Of 22 preoperative characteristics, 7 were associated with 379 (4.2%) potentially preventable 'medical' complications. Patients with ≥ 2 of the following, age ≥ 80 years, anticoagulant therapy, pulmonary disease, pharmacologically treated psychiatric disorder, anaemia and walking aids, composed 19.1% of the procedures; 55.7% constituted potentially preventable 'medical' complications that were mainly falls, mobilisation issues, pneumonias and cardiac arrhythmias. The number needed to be treated for a hypothetical intervention leading to 25% reduction in potentially preventable 'medical' complications was 34. THA, use of walking aids and cardiac disease were associated with 189 (2.2%) 'surgical' complications, but no clinically relevant preoperative prediction was possible. CONCLUSIONS: Preoperative identification of patients at high risk of preventable 'medical', but not 'surgical', complications is statistically possible. However, clinical relevance is limited. Future risk indices should differ between 'medical' and 'surgical' complications, and also consider 'preventability' of these. TRIAL REGISTRATION NUMBER: NCT01515670.
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Jørgensen et al. (2016) conducted a cohort in Elective primary unilateral total hip and knee arthroplasty (n=8,737). ≥2 preoperative medical predictors excluding hypertension (MPEH: age ≥80 years, anticoagulant therapy, pulmonary disease, pharmacologically treated psychiatric disorder, anaemia, and walking aids) vs. <2 preoperative medical predictors excluding hypertension (MPEH) was evaluated on Potentially preventable 'medical' complications resulting in hospitalisation >4 days or readmission within 30 days (NNT 34). Having ≥2 preoperative medical predictors identified 19.1% of fast-track arthroplasty procedures accounting for 55.7% of preventable medical complications.
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