Optimizing PatientOutcomes Following Orthopedic Surgery: The Role of Albuminand the Case For Fast-TrackAndrew NgRobin WangMentor: Atul Kamath, MD

Outline- The Role of Albumin as a Risk Factor for Patient Outcomes in Orthopedic

Surgery- Background- Aims and Significance- Methods- Results- Conclusions

- Optimizing Fast-Track Pathways: Identifying Key Patient-Level and Surgery-Level Predictors

- Background- Aims and Significance - Methods

Background- Risk factors for hospital readmissions

- Age, BMI, hemoglobin, GFR, albumin (Ellsworth et al, 2016)

- Albumin- Standard clinical definitions

- Marker for malnourishment - Immunocompromised patients (Bohl et

al, 2016 & Courtney et al, 2015)

Blood vessel

Albumin

Lymph fluid

Hypoalbuminemia HyperalbuminemiaNormal Albumin

3.5 g/dL 5.0 g/dL

Picture source: http://medifitbiologicals.com/vasodilators/

Background- Hip/Knee Arthroplasty

- Joint Replacement/Reconstruction- 2 Types

- Primary- Revision

Picture source: https://crouse.org/health/HIE%20Multimedia/1/002975.html

Why study albumin?- Aim

- Identify the relationship between serum albumin and cost of treatment for hip or knee arthroplasties

- Significance- Albumin has been correlated with higher

rates of hospital readmissions due to perioperative complications (Walls et al, 2015 & Merkow et al, 2015)

- Albumin linked to longer hospital stays (Bohl et al, 2016)

- Lack of literature evaluating overall treatment cost

Why study albumin?- Aim

- Identify the relationship between serum albumin and cost of treatment for hip or knee arthroplasties

- Significance- Albumin has been correlated with higher

rates of hospital readmissions due to perioperative complications (Walls et al, 2015 & Merkow et al, 2015)

- Albumin linked to longer hospital stays (Bohl et al, 2016)

- Lack of literature evaluating overall treatment cost

7x risk

Why study albumin?- Aim

- Identify the relationship between serum albumin and cost of treatment for hip or knee arthroplasties

- Significance- Albumin has been correlated with higher

rates of hospital readmissions due to perioperative complications (Walls et al, 2015 & Merkow et al, 2015)

- Albumin linked to longer hospital stays (Bohl et al, 2016)

- Lack of literature evaluating overall treatment cost

7x risk

0.42 days

Methods- Orthopedic Patient Data Obtained From UPHS Orthopedic Department

- January, 2014-December, 2016- 83 variables collected, 4763 total patients

- Excluded Data- 978 total observations dropped

- Albumin data missing (845)- Other missing variable data (98)- Outpatient data (28)- Procedures other than arthroplasty (5)- Outlier of cost (2)

- Multiple Linear Regressions Run Using Stata 14.1

Variables of Interest - Continuous variables (n = 3785)

Variable Mean Min Max

Cost 14772.37 2170.85 84952.97

Albumin (g/dL) 4.201215 2 5.5

BMI 33.05733 15 71

Age 62.40713 17 93

Hemoglobin (g/dL) 13.1525 5.7 19.6

Variables of Interest- Categorical variables (n = 3785)

Readmission Status

Readmitted Not Readmitted

Joint

Hip Knee

Procedure

Primary Revision

Distribution of Procedures

1091

152

2241

453

Procedure Type

Hip Primary Hip Revision Knee Primary Knee Revision

Results: Cost vs Joint/Procedure

0

5000

10000

15000

20000

25000

Knee Arthroplasty Hip Arthroplasty

Cost

($) Procedure Type

Cost vs Joint and Procedure Type

Primary

Revision

Results: Cost vs Albumin

0100002000030000400005000060000700008000090000

1.5 2 2.5 3 3.5 4 4.5 5 5.5 6

Cost

($)

Albumin (g/dL)

Cost vs Albumin for Patients at UPHS

Results: Readmissions vs AlbuminVariable Odds Ratio P value

Albumin 0.4916561 0.001*

BMI 1.021248 0.046

Age 1.021386 0.009*

Hb 0.9603124 0.481

GFR 0.6193554 0.072

Cost 1.000016 0.158

Joint Type 0.9370874 0.713

Revision Type 1.322878 0.247

Conclusions- Joint type (knee/hip) and procedure type (primary/revision) are the main drivers of

cost - Albumin significantly predicts cost- Lower albumin levels are associated with higher cost

- Albumin is a significant driver of readmissions

What’s Next?- Implications

- Pre-screening patients for albumin- Future prospective trial looking at the

relationship between albumin levels and cost/readmissions

- Implications for bundled payment - Limitations

- Albumin is likely correlated with other drivers of cost

- Limited physiologic data from patients

$

Albumin

Physiologic Factors

???

Outline- The Role of Albumin as a Risk Factor for Patient Outcomes in Orthopedic Surgery

- Background- Aims and Significance- Methods- Results- Conclusions

- Optimizing Fast-Track Pathways: Identifying Key Patient-Level and Surgery-Level Predictors

- Background- Aims and Significance - Methods

Background- Early discharge protocols reduce readmission and mortality rates while resulting in

significant economic savings- Fast-track pathways with a one-day length of stay (LOS) for total hip and knee

arthroplasty (THA/TKA) may optimize patient outcomes through multimodal strategies (Sibia, 2017):

- Early mobilization- Patient education- Non-opioid pain management- Aggressive postoperative fluid administration- Regional anesthesia

Background- Evidence that patients most likely to benefit tend to be younger, male, have lower

BMI, shorter surgical times, and received spinal anesthesia- Evidence that older age and pre-existing comorbidities present considerable risks

(Jorgensen, 2013)- Further identification of risk factors associated with positive and negative outcomes

in fast-track THA/TKA is warranted

Aims and Significance- Hip and knee replacement (MS-DRG 469/470) represents

Medicare’s most frequently occurring and costly procedure- 446,148 discharges annually and a budget of $6.6 billion

(CMS)- Increased implementation of fast-track protocols have

significant implications in cost savings - Medicare’s bundled payment programs

- 2013: Bundled Payment for Care Improvement Initiative (BPCI)

- 2016: Comprehensive Care for Joint Replacement (CRJ)

- Determine patient-level and surgery-level factors most relevant to outcomes and cost in fast-track protocols for THA/TKA: Identify the patients best suited for fast-track

Methods - Data Source: University Health Consortium (Vizient), Hospital of the University of

Pennsylvania- Key Variables

- Admission Characteristics: Day, Source, Severity- Demographics/Patient Characteristics: Age, Sex, BMI, Race, Ethnicity, Insurance Status,

Living Alone, Mobility Aids, Can Walk 2+ Blocks- Comorbidities: Diabetes, Hypertension, Coronary Artery Disease, COPD, Anemia, Renal

Failure, Psychiatric Medications- Surgery Characteristics: Operative Time, Surgical Approach, Anesthesia Type, Estimated

Blood Loss- Post-Surgery: Hours Until First PT, Distance Ambulated

- Compare demographic and clinical characteristics for fast-track pathway versus standard pathway patients: Which patients are the best candidates for fast-track?

Andrew: Lessons Learned

Balancing research and clinic

Critically evaluating data

Implementing research—what is “clinically relevant?”

Robin: Lessons Learned

Collaborative Nature of Research

Unexpected Obstacles

Translating Ideas into Practice

Acknowledgements• Dr. Atul Kamath• Pio Finnah• Paul Staehle• Joanne Levy• Safa Browne• SUMR 2017 Cohort

References: Albumin1. Bohl DD, Shen MR, Kayupov E, Della Valle CJ. Hypoalbuminemia independently predicts surgical site infection, pneumonia,

length of stay, and readmission after total joint arthroplasty. The Journal of Arthroplasty. 2016; 31(1): 15-21.2. Courtney PM, Rozell, JC, Melnic CM, Sheth NP, Nelson CL. The effect of malnutrition and morbid obesity on complication rates

following primary total joint arthroplasty. University of Pennsylvania Orthopaedic Journal. 2015; 25: 83-86.3. Ellsworth B, Kamath AF. Malnutrition and Total Joint Arthroplasty. J Nat Sci. 2016; 3(3): e179.4. Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the united

states. JAMA. 2015; 313(5): 483-495.5. Walls JD, Abraham D, Nelson CL, Kamath AF, Elkassabany NM, Liu J. Hypoalbuminemia more than morbid obesity is an

independent predictor of complications after total hip arthroplasty. The Journal of Arthroplasty. 2015; 30(12): 2290-2295.

References: Fast-Track 1. “Do Shorter Lengths of Stay Increase Readmissions After Total Joint Replacements?” Arthroplasty Today. (Sibia, 2017). 2. “Role of Patient Characteristics for Fast-track Hip and Knee Arthroplasty”. British Journal of Anesthesia. (Jorgensen, 2013).3. “Postoperative Morbidity and Discharge Destinations After Fast-Track Hip and Knee Arthroplasty in Patients Older Than 85

Years”. Society for Ambulatory Anesthesiology. (Pitter, 2016). 4. “Challenges in Post Discharge Function and Recovery: The Case of Fast-Track Hip and Knee Arthroplasty”. British Journal of

Anesthesia. (Aasvang, 2015). 5. “Fall-related Admissions After Fast-Track Total Hip and Knee Arthroplasty- Cause of Concern or Consequence of Success?”

Clinical Interventions in Aging. (Jorgensen 2013). 6. “New Medicare Data Available to Increase Transparency on Hospital Utilization.” Centers for Medicare & Medicaid Services.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-06-01.html (retrieved August 1, 2017).

Thank You!

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