Preoperative prediction of potentially preventable morbidity after fast-track hip and knee arthroplasty: a detailed descriptive cohort study

Christoffer C Jørgensen, Morten Aa Petersen, Henrik Kehlet, Lundbeck Foundation Centre for Fast-Track Hip and Knee Replacement Collaborative Group, Kjeld Soeballe, Torben B Hansen, Henrik Husted, Mogens B Laursen, Lars T Hansen, Per Kjærsgaard-Andersen, Søren Solgaard, Christoffer C Jørgensen, Morten Aa Petersen, Henrik Kehlet, Lundbeck Foundation Centre for Fast-Track Hip and Knee Replacement Collaborative Group, Kjeld Soeballe, Torben B Hansen, Henrik Husted, Mogens B Laursen, Lars T Hansen, Per Kjærsgaard-Andersen, Søren Solgaard

Abstract

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.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

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Figure 1
Relationship between per cent of complications and percentage of population for combinations of predictors and weightings. MPEH, medical predictors excluding hypertension.
Figure 2
Figure 2
Occurrence and fraction of specific types of ‘medical’ complications in patients with

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Occurrence and fraction of specific…

Figure 3

Occurrence and fraction of specific types of ‘severe medical’ complications in patients with…

Figure 3
Occurrence and fraction of specific types of ‘severe medical’ complications in patients with
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    1. Pearse RM, Harrison DA, James P et al. . Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006;10:R81 10.1186/cc4928 - DOI - PMC - PubMed
    1. Keats AS. The ASA classification of physical status—a recapitulation. Anesthesiology 1978;49:233–6. 10.1097/00000542-197810000-00001 - DOI - PubMed
    1. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991;78:355–60. 10.1002/bjs.1800780327 - DOI - PubMed
    1. Reynolds PQ, Sanders NW, Schildcrout JS et al. . Expansion of the surgical Apgar score across all surgical subspecialties as a means to predict postoperative mortality. Anesthesiology 2011;114:1305–12. 10.1097/ALN.0b013e318219d734 - DOI - PubMed
    1. Charlson ME, Pompei P, Ales KL et al. . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–83. 10.1016/0021-9681(87)90171-8 - DOI - PubMed
Show all 43 references
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Occurrence and fraction of specific types of ‘severe medical’ complications in patients with

References

    1. Pearse RM, Harrison DA, James P et al. . Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006;10:R81 10.1186/cc4928
    1. Keats AS. The ASA classification of physical status—a recapitulation. Anesthesiology 1978;49:233–6. 10.1097/00000542-197810000-00001
    1. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991;78:355–60. 10.1002/bjs.1800780327
    1. Reynolds PQ, Sanders NW, Schildcrout JS et al. . Expansion of the surgical Apgar score across all surgical subspecialties as a means to predict postoperative mortality. Anesthesiology 2011;114:1305–12. 10.1097/ALN.0b013e318219d734
    1. Charlson ME, Pompei P, Ales KL et al. . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–83. 10.1016/0021-9681(87)90171-8
    1. West MA, Lythgoe D, Barben CP et al. . Cardiopulmonary exercise variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded observational study. Br J Anaesth 2014;112:665–71. 10.1093/bja/aet408
    1. Grant SW, Hickey GL, Wisely NA et al. . Cardiopulmonary exercise testing and survival after elective abdominal aortic aneurysm repairdagger. Br J Anaesth 2015;114:430–6. 10.1093/bja/aeu383
    1. Bilimoria KY, Liu Y, Paruch JL et al. . Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg 2013;217:833–42. 10.1016/j.jamcollsurg.2013.07.385
    1. Hyder JA, Wakeam E, Habermann EB et al. . Derivation and validation of a simple calculator to predict home discharge after surgery. J Am Coll Surg 2014;218:226–36. 10.1016/j.jamcollsurg.2013.11.002
    1. Moonesinghe SR, Mythen MG, Das P et al. . Risk stratification tools for predicting morbidity and mortality in adult patients undergoing major surgery: qualitative systematic review. Anesthesiology 2013;119:959–81. 10.1097/ALN.0b013e3182a4e94d
    1. Kehlet H, Mythen M. Why is the surgical high-risk patient still at risk? Br J Anaesth 2011;106:289–91. 10.1093/bja/aeq408
    1. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189–98. 10.1097/SLA.0b013e31817f2c1a
    1. Kehlet H. Fast-track hip and knee arthroplasty. Lancet 2013;381:1600–2. 10.1016/S0140-6736(13)61003-X
    1. Starks I, Wainwright TW, Lewis J et al. . Older patients have the most to gain from orthopaedic enhanced recovery programmes. Age Ageing 2014;43:642–8. 10.1093/ageing/afu014
    1. Jorgensen CC, Kehlet H. Role of patient characteristics for fast-track hip and knee arthroplasty. Br J Anaesth 2013;110:972–80. 10.1093/bja/aes505
    1. den Hartog YM, Mathijssen NM, Hannink G et al. . Which patient characteristics influence length of hospital stay after primary total hip arthroplasty in a ‘fast-track’ setting? Bone Joint J 2015;97-B:19–23. 10.1302/0301-620X.97B1.33886
    1. Jorgensen CC, Kehlet H. Outcomes in smokers and alcohol users after fast-track hip and knee arthroplasty. Acta Anaesthesiol Scand 2013;57:631–8. 10.1111/aas.12086
    1. Jorgensen CC, Madsbad S, Kehlet H. Postoperative morbidity and mortality in type-2 diabetics after fast-track primary total hip and knee arthroplasty. Anesth Analg 2015;120:230–8. 10.1213/ANE.0000000000000451
    1. Krenk L, Rasmussen LS, Hansen TB et al. . Delirium after fast-track hip and knee arthroplasty. Br J Anaesth 2012;108:607–11. 10.1093/bja/aer493
    1. Jorgensen CC, Jacobsen MK, Soeballe K et al. . Thromboprophylaxis only during hospitalisation in fast-track hip and knee arthroplasty, a prospective cohort study. BMJ Open 2013;3:e003965 10.1136/bmjopen-2013-003965
    1. Savaridas T, Serrano-Pedraza I, Khan SK et al. . Reduced medium-term mortality following primary total hip and knee arthroplasty with an enhanced recovery program. A study of 4,500 consecutive procedures. Acta Orthop 2013;84:40–3. 10.3109/17453674.2013.771298
    1. Kehlet H, Jorgensen CC. Predicting postoperative morbidity: in what procedures and what patients? Anesthesiology 2014;120:1297 10.1097/ALN.0000000000000214
    1. Jans O, Jorgensen C, Kehlet H et al. . Role of preoperative anemia for risk of transfusion and postoperative morbidity in fast-track hip and knee arthroplasty. Transfusion 2014;54:717–26. 10.1111/trf.12332
    1. Jorgensen CC, Kehlet H. Fall-related admissions after fast-track total hip and knee arthroplasty—cause of concern or consequence of success? Clin Interv Aging 2013;8:1569–77. 10.2147/CIA.S52528
    1. Jorgensen CC, Knop J, Nordentoft M et al. . Psychiatric disorders and psychopharmacologic treatment as risk factors in elective fast-track total hip and knee arthroplasty. Anesthesiology 2015;123:1281–91. 10.1097/ALN.0000000000000632
    1. Husted H, Solgaard S, Hansen TB et al. . Care principles at four fast-track arthroplasty departments in Denmark. Dan Med Bull 2010;57:A4166.
    1. Andersen TF, Madsen M, Jorgensen J et al. . The Danish National Hospital Register. A valuable source of data for modern health sciences. Dan Med Bull 1999;46:263–8.
    1. Johannesdottir SA, Horváth-Puhó E, Schmidt M et al. . Existing data sources for clinical epidemiology: the Danish National Database of Reimbursed Prescriptions. Clin Epidemiol 2012;4:1–11.
    1. Hosmer DW, Lemenshow S. Applied logistic regression. 2nd edn New York: Wiley, Inc, 2000.
    1. Cannesson M, Ani F, Mythen MM et al. . Anaesthesiology and perioperative medicine around the world: different names, same goals. Br J Anaesth 2015;114:8–9. 10.1093/bja/aeu265
    1. Grocott MP, Pearse RM. Perioperative medicine: the future of anaesthesia? Br J Anaesth 2012;108:723–6. 10.1093/bja/aes124
    1. van Walraven C, Jennings A, Forster AJ. A meta-analysis of hospital 30-day avoidable readmission rates. J Eval Clin Pract 2012;18:1211–18. 10.1111/j.1365-2753.2011.01773.x
    1. Brown EG, Burgess D, Li CS et al. . Hospital readmissions: necessary evil or preventable target for quality improvement. Ann Surg 2014;260:583–9. 10.1097/SLA.0000000000000923
    1. Harari D, Hopper A, Dhesi J et al. . Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing 2007;36:190–6. 10.1093/ageing/afl163
    1. Foss NB, Christensen DS, Krasheninnikoff M et al. . Post-operative rounds by anaesthesiologists after hip fracture surgery: a pilot study. Acta Anaesthesiol Scand 2006;50:437–42. 10.1111/j.1399-6576.2005.00944.x
    1. Walke LM, Rosenthal RA, Trentalange M et al. . Restructuring care for older adults undergoing surgery: preliminary data from the Co-Management of Older Operative Patients En Route Across Treatment Environments (CO-OPERATE) model of care. J Am Geriatr Soc 2014;62:2185–90. 10.1111/jgs.13098
    1. Husted H, Jorgensen CC, Gromov K et al. . Low manipulation prevalence following fast-track total knee arthroplasty. Acta Orthop 2015;86:86–91. 10.3109/17453674.2014.964615
    1. Khan SK, Malviya A, Muller SD et al. . Reduced short-term complications and mortality following enhanced recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures. Acta Orthop 2014;85:26–31. 10.3109/17453674.2013.874925
    1. Vetter TR, McGwin G Jr. Fast food nation and fast-track arthroplasty: can we have our cake and eat it too? Anesth Analg 2015;120:5–7. 10.1213/ANE.0000000000000478
    1. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. 10.1097/
    1. Slankamenac K, Nederlof N, Pessaux P et al. . The comprehensive complication index: a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials. Ann Surg 2014;260:757–62. 10.1097/SLA.0000000000000948
    1. Grocott MP, Browne JP, Van der Meulen J et al. . The postoperative morbidity survey was validated and used to describe morbidity after major surgery. J Clin Epidemiol 2007;60:919–28. 10.1016/j.jclinepi.2006.12.003
    1. van Walraven C, Bennett C, Jennings A et al. . Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ 2011;183:E391–402. 10.1503/cmaj.101860

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