And those most affected are African Americans, poor, uninsured and rural residents.

Researchers from the University of California, San Francisco examined changes in driving time to trauma centers, which have increasingly been shuttered in recent years. They found that by 2007, 69 million Americans — nearly one in four — had to travel farther to the nearest trauma center than they traveled in 2001.

“Trauma centers aren’t just for ‘certain’ people — if you sustain a serious injury from a car accident or fall off your roof, you need a trauma center,’’ said lead author Dr. Renee Y. Hsia, an assistant professor of emergency medicine at UCSF. She is also an attending physician in the emergency department at San Francisco General Hospital & Trauma Center and a Robert Wood Johnson Foundation Physician Faculty Scholar.

“We found evidence that vulnerable communities have less geographic access to trauma care, adding to their health disparities,’’ Hsia said in a news release. “This study will help us better understand how trauma center closures are affecting people.’’

Hsia’s research centers on illustrating inequalities in accessing trauma care as well as the decline of emergency care in the United States. She has documented that tens of millions of Americans do not have ready access to a certified trauma center, and that nearly a third of urban and suburban emergency rooms have closed in the last two decades.

Trauma services are not, as commonly believed, available in all hospitals. They are hospitals with emergency departments that provide specialty care for injured patients, regardless of ability to pay. As a result, trauma centers face greater financial jeopardy depending on the surrounding patient population.

For their new study, the researchers analyzed 31,475 ZIP codes in the United States, covering some 283 million people, nearly the entire nation.

Overall, nearly three-quarters of the U.S. lives within 10 miles of a trauma center. Of the remainder, 14 percent live more than 30 miles from a trauma center.

Communities with a higher number of residents under the federal poverty level, black residents, uninsured residents and rural residents faced longer drives compared to communities with a low share of these vulnerable populations.

For nearly 16 million people, the extra driving time amounts to about 30 minutes — a critical period for people facing life-threatening injuries such as stroke and gunshot wounds.

In 1990 there were 1,125 trauma centers in the United States; by 2005, about 30 percent of them had closed primarily because of the high costs and fewer patients able to pay the bills. The majority of closures took place in urban areas but rural communities have also been affected.

The authors recommend policy makers should subsidize trauma centers that treat a large number of African American, uninsured or poor people. In rural areas, they recommend that hospitals establish agreements with nearby trauma centers to ease transfers of seriously injured patients.

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An analysis of Medicare data showed a higher death risk if the stent was inserted by a doctor who performed less than six procedures a year, or if the procedure was conducted early in the physician’s career.

Carotid stenting is increasingly being used to treat severe carotid atherosclerosis, an important cause of ischemic stroke. Since approval of the first carotid stent system by the U.S. Food and Drug Administration in 2004, use of carotid stenting has more than doubled in Medicare beneficiaries.

Despite the promise of this procedure, its increasing use has raised potential concerns.

“Carotid stenting is a technically demanding procedure and earlier studies have demonstrated a substantial learning curve with it,” says lead study author Dr. Brahmajee K. Nallamothu, cardiologist at the University of Michigan Cardiovascular Center, in a news release. “The total number of operators currently performing carotid stenting in routine clinical practice and their overall experiences and outcomes with the procedure remain largely unknown.

Nallamothu and colleagues at the U-M Health System, Mayo Clinic, Dartmouth-Hitchcock Medical Center, and Yale University School of Medicine conducted a study to examine recent patterns of utilization and outcomes for carotid stenting in the U.S. among elderly patients.

The researchers used administrative data from fee-for-service Medicare beneficiaries ages 65 years or older who underwent carotid stenting between 2005 and 2007. Among the outcomes the researchers measured were 30-day mortality and treatment early vs. late during an operator’s experience.

Analysis of the data identified 24,701 patients who underwent carotid stenting by 2,339 operators. Average age of the patients in the study was 76.2 years.

Compared with patients treated by operators performing 24 or more procedures per year, those treated by operators performing less than six procedures per year were nearly twice as likely to die within 30 days of the stent placement, the study showed.

The authors found higher 30-day mortality in patients treated early vs. late during a new operator’s experience (2.3 percent vs. 1.4 percent, respectively). Compared with patients who were their operator’s 12th procedure or higher, those who were among their operator’s first 11 procedures had a 1.7 times higher odds of dying within 30 days of the procedure.

“In conclusion, many physicians have begun performing carotid stenting in Medicare beneficiaries during recent years, although most operators appear to have developed limited experience with the procedure over time, “ study authors write. “This finding is important since adjusted outcomes following the procedure are worse among very low-volume operators and early during an operator’s experience. Given limitations of these data, caution should be exerted when using our findings to set specific targets for operator experience.”

Collecting more detailed data about operator experience during the early dissemination of new procedures, like carotid stenting, may help optimize outcomes, according to the researchers.

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Although most patients would allow residents and medical students to be involved in their operation, researchers say the rates of consent vary depending on the type of surgery and the trainee’s level of participation

Dr. Christopher R. Porta and colleagues from Madigan Army Health System, Tacoma, Wash., conducted an anonymous questionnaire at a tertiary-level U.S. Army hospital and referral center, to evaluate patient perceptions and willingness to participate in surgical resident education and training programs.

“Currently, no widely accepted guidelines or policies exist for providing information regarding the role of surgical trainees to the patient during the informed consent process,” the authors write. “The accepted standard is to provide information that ‘a reasonable patient’ would want and would need to know to make an informed decision, but this counseling may vary widely by health care professional, setting, and type of surgical procedure.”

The authors distributed 500 surveys, 316 (63.2 percent) of which were returned and included in the study. Most patients indicated no preference for a private hospital versus a teaching hospital, however of those who did, more preferred a teaching hospital to a private facility for overall care (24.9 percent vs. 8.8 percent) and minor surgical procedures (28.2 percent vs. 12 percent), but hospital preference for major surgical procedures was similar (24.7 percent vs. 26.6 percent).

Additionally, 91.2 percent of those patients who indicated a facility preference reported that their care in a teaching hospital would be equivalent to or better than that of a private hospital.

Patients also indicated they overwhelmingly preferred to be informed of resident participation in their surgical procedure, regardless of whether it was a major procedure (95.7 percent) or a minor surgery (87.5 percent).

A total of 94 percent of respondents indicated they would consent to involvement of a surgical resident, however this decreased to 85 percent for a surgical intern and 79.9 percent for medical student involvement.

When provided with specific scenarios involving trainee participation, 57.6 percent of patients consented to having a junior resident act as the first assistant, 25.6 percent consented to the resident acting as the operation surgeon with direct staff observation, and 18.2 percent consented to resident participation without direct staff observation.

“Although most patients express an overall willingness to participate in surgical education, wide variations can be observed in the actual consent rates for specific training situations, “ the authors said. “This decreased willingness to consent and the potential effect on training programs must be considered when discussing policy initiatives aimed at improving informed consent.”

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Researchers analyzed data from the Nationwide Inpatient Sample — a national database of hospital discharge records — from 1993-2008 and found a significant increase in infections related to cardiac electrophysiological devices or CIED.

Their analysis found that the annual incidence of CIED-related infection increased by 210 percent over the 16-year period studied. 

Further analysis showed a jump in infections after 2004, directly correlating with an increase in four major comorbidities or other medical conditions: renal failure, respiratory failure, heart failure and diabetes.

“We believe the growing number of clinical comorbidities in this patient population plays a large role in the increase in infections associated with CIEDs,” said Dr. Arnold J. Greenspon, professor of medicine at Jefferson Medical College of Thomas Jefferson University, director of Cardiac Electrophysiology at Thomas Jefferson University Hospital, and lead author of the study. “The patients are sicker, which may place them at higher risk for infection.”

Pacemakers and implantable cardioverter-defibrillators or ICDs are important in regulating the electrical signaling to the heart. Pacemakers help to speed up a slow heart rhythm (bradycardia) whereas ICDs help to slow down rapid heart rhythm (tachycardia), a potentially life-threatening condition.

The study showed a 96 percent increase in CIED implantation, mostly due to a marked increase in the use of ICDs.

“The expanding indications for ICD implantation may have contributed to the rise in infections since many of these patients have multiple medical co-morbidities,” said Dr. Greenspon. The highest infection rates occurred in white males over 65.

“The number of Americans receiving pacemakers and defibrillators has dramatically increased. This analysis shows that the infection risk associated with these devices has, unfortunately, increased as well,” said Greenspon. “A better understanding of the risk factors for infection will improve patient care and, hopefully, reduce the prolonged hospital stays that often result.”

Rising CIED infection rates also have economic implications for hospitals, as these patients require prolonged hospital stays which are associated with increased costs.

Researchers say further investigation into the risk factors that predict CIED infection or therapies to mitigate this issue is warranted.

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According to researchers, thyroidectomy is a common operation, but it can be associated with serious complications: paralysis of the recurrent laryngeal nerve (RLN, a nerve that transmits motor function and sensation to the larynx, or voice box) and hypoparathyroidism (caused by injury to the parathyroid glands, which make a hormone that controls calcium levels).

Unintentional damage to the RLN by this surgery is reported to cause nerve paralysis in one percent to two percent of cases. Extensive searching for the RLN during thyroid surgery may cause temporary or permanent hypoparathyroidism.

The authors note two methods of identifying the RLN: one approach locates the nerve where it enters the larynx (superior-inferior direction), and the other approach locates the nerve in the trachea-esophageal groove, and traces it in the superior direction (inferior-superior direction).

Dr. Bayram Veyseller, from Bezmialem Vakif University, Istanbul, Turkey, and colleagues conducted a study to compare both techniques. They studied patients undergoing partial or total thyroidectomy between January 2006 and August 2009.

In 67 patients, the superior-inferior RLN identification technique was used, and in 128 patients, the inferior-superior method was used, according to the attending surgeon’s preference.

Researchers evaluated patients’ vocal cord function and blood calcium levels on the first day after the surgery. Follow-up was conducted every three months until patients’ calcium levels improved, for an average of 26 months.

If at the one-year mark blood calcium levels were still low (a sign of hypoparathyroidism) or RLN paralysis did not improve, the conditions were considered permanent.

Permanent paralysis of the RLN occurred in two patients in the inferior-superior group, and none in the other group. Hypoparathyroidism among the superior-inferior group patients was temporary in four and permanent in none; among the inferior-superior group patients, 14 experienced temporary hyperthyroidism and four experienced permanent hypoparathyroidism.

Overall, significantly fewer complications were found in terms of RLN paralysis and hypoparathyroidism in the superior-inferior group, which is when surgeons locate the nerve where it enters the larynx.

“Significantly lower rates of RLN paralysis and hypoparathyroidism were observed in thyroidectomies using a superior-inferior approach,” the authors concluded. They added that more studies should be conducted to corroborate these results.

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Xarelto (rivaroxaban) is a pill taken once daily. Those undergoing a knee replacement should take the medication for 12 days and patients undergoing a hip replacement procedure should take Xarelto for 35 days.

The safety and effectiveness of Xarelto was evaluated in patients undergoing hip replacement surgery and patients undergoing knee replacement surgery. Clinical studies were designed to identify occurrence of venous thromboembolic events (VTE), deep vein thrombosis (DVT), pulmonary embolism (PE) or death in patients treated. Treatment with Xarelto was compared to treatment with enoxaparin, a drug that prevents DVTs or blood clotting.

“Xarelto represents a new oral treatment option to help prevent blood clotting in patients receiving a hip or knee replacement,” said Dr. Richard Pazdur, director of the Office of Oncology Drug Products in the FDA’s Center for Drug Evaluation and Research, in a news release. Xarelto was reviewed by the Division of Hematology Products within the Office of Oncology Drug Products.

More than 6,000 patients undergoing hip or knee replacement surgery received Xarelto in clinical studies. Among patients undergoing knee replacement surgery, 9.7 percent of those treated with Xarelto had VTE compared with 18.8 percent of patients who received enoxaparin.

In a study involving hip replacement surgery, 1.1 percent of patients who received Xarelto had VTE compared with 3.9 percent of those who received enoxaparin. In another study of hip replacement patients, 2.0 percent of those treated with Xarelto had VTE compared with 8.4 percent of those who received enoxaparin.

The most common side effect observed in patients treated with Xarelto was bleeding.
Other FDA approved drugs to prevent blood clotting include Lovenox (enoxaparin), generic versions of enoxaparin, Arixtra (fondaparinux), Fragmin (dalteparin) for hip replacement surgery only, Coumadin (warfarin) and heparin.

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“Our data demonstrate that obesity is a major risk factor for complications following certain kinds of elective surgery,” said Dr. Marty Makary, an associate professor of surgery at the Johns Hopkins University School of Medicine and leader of the study.

Not only are these findings relevant to physicians due to potential surgical site infections in heavier patients but also to policymakers whose metrics for surgical quality and reimbursement do not account for the higher risk of worse outcomes in the obese.

“With the government and other insurers penalizing doctors whose patients get infections or are readmitted to the hospital — and with obese patients more likely to have those problems — policymakers need to make sure they aren’t giving physicians financial incentives to discriminate on the basis of weight,” Makary said in a news release.

In the study, Makary and his colleagues examined insurance claims data from seven Blue Cross and Blue Shield plans and identified patients who underwent elective breast procedures covered by insurance between 2002 and 2006. There were 2,403 patients in the obese group and 5,597 patients in the normal weight control group. The most common procedure, by far, was breast reduction, followed by breast reconstruction, augmentation and breast lift.

Within 30 days of surgery, 18.3 percent of the obese group experienced at least once complication, compared to 2.2 percent of patients in the control group. The differences between the two groups were most pronounced in complications, such as inflammation (with obese patients 22 times more likely to suffer a complication), infection (13 times) and pain (11 times).

Thirty-four percent of adults in the United States are now estimated to be obese, up from just 15 percent a decade ago. Meanwhile, the number of people nationwide having elective plastic surgery has also increased in recent years — with annual plastic surgery volume up 725 percent between 1992 and 2005.

Surgical outcomes are increasingly judged using standardized measures to evaluate quality and to inform the public and insurance companies. These metrics also are used more and more to penalize hospitals with higher complication rates. But, Makary says, they do not take into account that obese patients may suffer more complications, as this new research finds.

Operations on obese patients are more taxing, says Makary, a surgeon himself. These surgeries usually take longer, the operating fields are deeper, the spaces in which an infection can set in are often greater and blood flow in fat tissue is less than in other types of tissue, which results in slower healing, he says.

“But payments are based on the complexity of the procedure and are not adjusted for the complexity of the patient,” he said.

“There are definitely incentives there for surgeons and institutions to select healthier patients,” he said. “They’re getting reimbursed less per unit of work for obese patients.”

According to Makary, more research needs to be done on the role of obesity in surgical complications covering a wider variety of surgeries so that new metrics can be developed to account for any differences due to obesity.

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The survey found that 59 percent of physicians acknowledged having less empathy for so-called frequent users than other patients, and 77 percent held bias for frequent users. Physicians defined frequent users in the survey as patients who visit the ED at least 10 times a year.

Other highlights of the survey include:

• 91 percent of physicians say frequent users pose challenges for the ED.
• 71 percent of physicians believe a program to manage frequent users is necessary.
• 82 percent of physicians say they feel some level of burnout.
• Experience did not shield physicians from burnout.

Physicians who responded to the survey comprised seasoned professionals, up-and-coming residents and alumni whose experience ranged from one year to 30 years. They represented every state, except Alaska.

While frequent users long have been linked with provoking negative attitudes in the ED, the survey’s findings are believed to be the first time physicians’ opinions have been measured. The findings were presented at the annual meeting of the Society for Academic Emergency Medicine June 1-5 in Boston.

“Our findings should be a wake-up call for hospital administrators to look at ways to manage these types of patients,” said Dr. Jennifer Peltzer-Jones, a clinical psychologist at Henry Ford’s Department of Emergency Medicine who led the survey, in a press release.  In 2004, the hospital created the Community Resources for Emergency Department Overuse (CREDO) in response to increased frequent users in its ED.

“Only 31 percent of the physicians surveyed said they had a program to help manage patients who are frequent users. Hospital administrators have to realize that these patients are invoking burnout and staff want and need additional resources,” Dr. Peltzer-Jones says.

Findings were compiled from an 18-question, anonymous survey randomly sent to 1,500 physicians nationally between July-October 2010. Of the 1,500 surveys sent, 418 physicians responded.

“People go to the Emergency Department because it’s accessible 24/7,” Dr. Peltzer-Jones says. “However, the ED is meant for emergent care, not primary care. ED physicians are not equipped to be primary care providers and case managers.”

Dr. Peltzer-Jones says many social factors contribute to patients frequently using the ED: lack of access to primary and specialty care, homelessness, lack of transportation for appointments, substance abuse, psychiatric disorders and chronic medical conditions.

Contrary to popular belief, many frequent users do have some type of medical insurance, she says.

“Physicians are feeling frustrated because they want to assist their patients who have emergent care issues. But they find they are managing chronic medical and social problems with very little resources ,” Dr. Peltzer-Jones said in the release. “The Emergency Department is supposed to be the last, not first, resource for patient care. That’s not the case with the frequent user population.”

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From 1999 to 2009, the age-adjusted death rate in the United States declined from 881.9 per 100,000 population to 741.0, a record low.

Contributing factors for the advances in public health include the development of new vaccines, awareness campaigns, health screening, new legislation and preparedness.

Public health scientists at the Centers for Disease Control and Prevention, were asked to nominate noteworthy public health achievements that occurred in the United States during 2001 – 2010. From those nominations, 10 achievements, not ranked in any order, have been identified.

Vaccine-Preventable Diseases

The past decade has seen substantial declines in cases, hospitalizations, deaths, and health-care costs associated with vaccine-preventable diseases. New vaccines were introduced, bringing to 17 the number of diseases targeted by U.S. immunization policy.

A recent economic analysis indicated that vaccination of each U.S. birth cohort with the current childhood immunization schedule prevents approximately 42,000 deaths and 20 million cases of disease, with net savings of nearly $14 billion in direct costs and $69 billion in total societal costs.

Prevention and Control of Infectious Disease

Improvements in state and local public health infrastructure along with innovative and targeted prevention efforts yielded significant progress in controlling infectious diseases. Examples include a 30 percent reduction from 2001 to 2010 in reported U.S. tuberculosis cases and a 58 percent decline from 2001 to 2009 in central line–associated blood stream infections.

Other major advances include the capacity to identify contaminated foods rapidly and accurately and prevent further spread; expanded HIV screening of persons aged 13–64 years, and new blood donor screening for the West Nile virus. To date, such screening has interdicted 3,000 potentially infected U.S. donations, removing them from the blood supply.

Tobacco Control

By 2009, 20.6 percent of adults and 19.5 percent of youths were current smokers, compared with 23.5 percent of adults and 34.8 percent of youths 10 years earlier. However, progress in reducing smoking rates among youths and adults appears to have stalled in recent years.

Although no state had a comprehensive smoke-free law (i.e., prohibit smoking in worksites, restaurants, and bars) in 2000, that number increased to 25 states and the District of Columbia (DC) by 2010, with 16 states enacting comprehensive smoke-free laws following the release of the 2006 Surgeon General’s Report.

In 2009, the largest federal cigarette excise tax increase went into effect, bringing the combined federal and average state excise tax for cigarettes to $2.21 per pack, an increase from $0.76 in 2000. By 2010, FDA had banned flavored cigarettes, established restrictions on youth access, and proposed larger, more effective graphic warning labels that are expected to lead to a significant increase in quit attempts.

Maternal and Infant Health

The past decade has seen significant reductions in the number of infants born with neural tube defects (NTDs) and expansion of screening of newborns for metabolic and other heritable disorders. Mandatory folic acid fortification of cereal grain products labeled as enriched in the United States beginning in 1998 contributed to a 36 percent reduction in NTDs from 1996 to 2006 and prevented an estimated 10,000 NTD-affected pregnancies in the past decade, resulting in a savings of $4.7 billion in direct costs.

Improvements in technology and endorsement of a uniform newborn-screening panel of diseases have led to earlier life-saving treatment and intervention for at least 3,400 additional newborns each year with selected genetic and endocrine disorders. Newborn screening for hearing loss increased from 46.5 percent in 1999 to 96.9 percent in 2008.

Motor Vehicle Safety

Motor vehicle crashes are among the top 10 causes of death for U.S. residents of all ages and the leading cause of death for persons aged 5 to 34 years. In terms of years of potential life lost before age 65, motor vehicle crashes ranked third in 2007, behind only cancer and heart disease.

From 2000 to 2009, the death rate related to motor vehicle travel declined from 14.9 per 100,000 population to 11.0, and the injury rate declined from 1,130 to 722; among children, the number of pedestrian deaths declined by 49 percent, from 475 to 244, and the number of bicyclist deaths declined by 58 percent, from 178 to 74.

These successes largely resulted from safer vehicles, safer roadways, and safer road use. Behavior was improved by protective policies, including effective seat belt and child safety seat legislation; 49 states and the DC have enacted seat belt laws for adults, and all 50 states and DC have enacted legislation that protects children riding in vehicles.

Cardiovascular Disease Prevention

Preliminary data from 2009 indicate that stroke is now the fourth leading cause of death in the United States. During the past decade, the age-adjusted coronary heart disease and stroke death rates declined from 195 to 126 per 100,000 population and from 61.6 to 42.2 per 100,000 population. Factors contributing to these reductions include declines in the prevalence of cardiovascular risk factors such as uncontrolled hypertension, elevated cholesterol, and smoking, and improvements in treatments, medications, and quality of care.

Occupational Safety

Significant progress was made in improving working conditions and reducing the risk for workplace-associated injuries. For example, patient lifting has been a substantial cause of low back injuries among the 1.8 million U.S. health-care workers in nursing care and residential facilities. In the late 1990s, an evaluation of a best practices patient-handling program that included the use of mechanical patient-lifting equipment demonstrated reductions of 66 percent in the rates of workers’ compensation injury claims and lost workdays and documented that the investment in lifting equipment can be recovered in less than 3 years.

The annual cost of farm-associated injuries among youth has been estimated at $1 billion annually. A comprehensive childhood agricultural injury prevention initiative was established to address this problem, resulting in a 56 percent decline in youth farm injury rates from 1998 to 2009.

Cancer Prevention

Evidence-based screening recommendations have been established to reduce mortality from colorectal cancer and female breast and cervical cancer. From 1998 to 2007, colorectal cancer death rates decreased from 25.6 per 100,000 population to 20.0 (2.8 percent per year) for men and from 18.0 per 100,000 to 14.2 (2.7 percent per year) for women. During this same period, smaller declines were noted for breast and cervical cancer death rates (2.2 percent per year and 2.4 percent, respectively).

Childhood Lead Poisoning Prevention

In 2000, childhood lead poisoning remained a major environmental public health problem in the United States, affecting children from all geographic areas and social and economic levels. In 1990, five states had comprehensive lead poisoning prevention laws; by 2010, 23 states had such laws. Findings of the National Health and Nutrition Examination Surveys from 1976 to 1980 to 2003 to 2008 reveal a steep decline, from 88.2 percent to 0.9 percent, in the percentage of children aged 1 to 5 years. The economic benefit of lowering lead levels among children by preventing lead exposure is estimated at $213 billion per year.

Public Health Preparedness and Response

After the international and domestic terrorist actions of 2001 highlighted gaps in the nation’s public health preparedness, tremendous improvements have been made. In the first half of the decade, efforts were focused primarily on expanding the capacity of the public health system to respond (e.g., purchasing supplies and equipment). In the second half of the decade, the focus shifted to improving the laboratory, epidemiology, surveillance, and response capabilities of the public health system.

During the 2009 H1N1 influenza pandemic, these improvements in the ability to develop and implement a coordinated public health response in an emergency facilitated the rapid detection and characterization of the outbreak, deployment of laboratory tests, distribution of personal protective equipment from the Strategic National Stockpile, development of a candidate vaccine virus, and widespread administration of the resulting vaccine. These public health interventions prevented an estimated 5 to 10 million cases, 30,000 hospitalizations, and 1,500 deaths (CDC, unpublished data, 2011).

For more on public health issues, see the library of articles by Daytona Beach personal injury attorney.

Average hospital stays after total hip arthroplasty (replacement) has gone from 9 days in 1991 to 3.5 days in 2008, according to analysis of data from Medicare beneficiaries who underwent hip replacement or subsequent follow-up corrective surgery between 1991 and 2008.

That’s both good and bad news for hip replacement patients.

“The good news is you don’t have to stay in the hospital to recover,” said Dr. Peter Cram,  of the University of Iowa’s Roy J. and Lucille A. Carver College of Medicine and lead researcher on the study, in a press release. “The bad news is that you’re not in the hospital while you’re recovering.”

Total hip arthroplasty is a safe and effective therapy for patients with advanced degenerative joint disease. In recent years, there has been a dramatic increase in performance of this procedure both in the United States and abroad.

There is a general assumption that increasing experience with total hip arthroplasty has resulted in improvements in patient outcomes, as has been observed in other procedures, but rigorous empirical data documenting such improvement are limited. This lack of data are striking given that an estimated 280,000 total hip arthroplasty procedures are performed annually at a cost of more than $12 billion, according to background information in the article.

Cram and Yue Li, associate professor of internal medicine at the UI Carver College of Medicine, evaluated the long-term trends in the outcomes of Medicare beneficiaries undergoing primary hip replacement and follow-up corrective surgery and to explore whether reductions in hospital length of stay (LOS) might be associated with increased discharge of patients to postacute care settings, increased readmission rates, or a combination of both outcomes.

The study included data from between 1991 and 2008 on 1,453,493 Medicare Part A beneficiaries who underwent primary total hip arthroplasty and 348,596 who underwent revision total hip arthroplasty.

“In an analysis of 1991-2008 Medicare administrative data, 3 trends were identified. First, we found that despite increasing patient complexity, both unadjusted and adjusted mortality for primary total hip arthroplasty showed substantial improvement over time,” the authors note in the study. “Conversely, our second finding was that for revision total hip arthroplasty, unadjusted mortality appeared to increase modestly but this increase was largely explained by increasing patient complexity. Third and most importantly, marked declines in hospital LOS for both primary and revision total hip arthroplasty seemed to correspond with an increase in the proportion of patients who were discharged to postacute care and an increase in patient readmissions.”

For primary total hip arthroplasty, average hospital LOS decreased from 9.1 days to 3.7 days. After adjustment for patient characteristics, risk-adjusted 30-day mortality over the study period decreased from 0.7 percent to 0.3 percent and 90-day mortality decreased from 1.3 percent to 0.7 percent.

“What we found is that patients are staying in the hospital a much shorter amount of time, patient mortality is increasingly low, but an increasing number of patients are requiring readmission 30 to 90 days after their initial surgery,” Cram said.

The researchers also found that the proportion of primary total hip arthroplasty patients discharged to home decreased from 68 percent in 1991-1992 to 48.2 percent in 2007-2008, while the proportion of patients discharged to skilled or intermediate care increased from 17.8 percent to 34.3 percent. The 30-day all-cause readmission rate decreased from 5.9 percent in 1991-1992 to 4.6 percent in 2001-2002, before increasing to 8.5 percent in 2007-2008. Results were similar for 90-day readmission rates.

“For revision total hip arthroplasty, similar trends were observed in hospital LOS, in-hospital mortality, discharge disposition, and hospital readmission rates,” the authors write.

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