J Knee Surg 2023; 36(11): 1141-1149
DOI: 10.1055/s-0042-1750063
Original Article

What Are the Drivers of Readmission for Serious Venous Thromboembolic Events after Primary Total Knee Arthroplasty? An Analysis of 862,915 Patients

Colin Rhoads
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Ahmed K. Emara
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Thomas Pumo
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Xuankang Pan
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Case Western Reserve University, School of Medicine, Cleveland, Ohio
,
Guangjin Zhou
3   Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
,
Siran Koroukian
3   Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
,
Viktor E. Krebs
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
1   Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
› Institutsangaben
Funding None.

Abstract

Venous thromboembolism (VTE) is a relatively common complication among patients undergoing primary total knee arthroplasty (TKA). This complication occurs in a spectrum of severity ranging from an incidental finding to serious readmission-requiring events. To date, the risk factors of serious VTE that require readmission have not been characterized. This study examines the patient and hospital characteristics associated with readmission for serious VTE after TKA. The National Readmission Database (NRD) from the Agency of Healthcare Research and Quality (AHRQ) was queried for patients who underwent primary TKA from January 2016-December 2018. The study population consisted of patients who were readmitted within 90 days following primary TKA with a primary diagnosis of VTE. Multivariable regression models were constructed to evaluate patient characteristics (age, sex, insurance, elective nature of procedure, hospital characteristics, discharge status, income, and comorbidities) associated with higher risk of developing readmission-requiring VTE. Readmission rates for VTE exhibited a higher incidence in patients older than 61 (compared with 40 and under), males (OR:1.08, 95%CI [1.03–1.14]), patients with nonelective procedures (OR:20.21, 95% CI [19.16–21.32]), patients at large hospitals(OR:1.17, 95% CI [1.09–1.25]), patients at private hospitals (OR:1.19, 95% CI [1.09–1.29]), and patients with non-home discharge statuses. Comorbidities of paralysis (OR:1.52, 95% CI [1.19–1.94]), neurological disorders (OR:1.12, 95% CI [1.02–1.23]), metastatic cancer (OR:1.48, 95% CI [1.01–2.17]), obesity (OR:1.11, 95% CI [1.06–1.17]), fluid and electrolyte imbalance (OR:1.28, 95% CI [1.18–1.38]), blood loss anemia (OR:1.29, 95% CI [1.02–1.64]), and iron deficiency anemia (OR:1.24, 95 % CI [1.15–1.33]) increased risk of VTE. Certain comorbidities requiring chronic anticoagulation were associated with lower risk of VTE. Insurance status and patient income did not exhibit any correlation with VTE incidence. Patient characteristics of male sex, age > 61, and baseline comorbidities (paralysis, neurological disorders, metastatic cancer, obesity, fluid and electrolyte imbalance, and blood loss/iron deficiency anemia) were at an increased risk of developing serious VTE. Patients without continued supervision at their discharge environment were at higher risk of developing serious VTE. Extra prophylaxis and special protocols may be warranted in these patients to prevent VTE complications.

Supplementary Material



Publikationsverlauf

Eingereicht: 16. Dezember 2021

Angenommen: 26. April 2022

Artikel online veröffentlicht:
07. Juli 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Falck-Ytter Y, Francis CW, Johanson NA. et al. Prevention of VTE in Orthopedic Surgery Patients: Antithrombotic Therapy and Prevention of Thrombosis. 9th ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) e278S-e325S
  • 2 Santana DC, Emara AK, Orr MN. et al. An update on venous thromboembolism rates and prophylaxis in hip and knee arthroplasty in 2020. Medicina (Kaunas) 2020; 56 (09) 416
  • 3 Matzko C, Berliner ZP, Husk G, Mina B, Nisonson B, Hepinstall MS. Equivalent VTE rates after total joint arthroplasty using thromboprophylaxis with aspirin versus potent anticoagulants: retrospective analysis of 4562 cases across a diverse healthcare system. Arthroplasty 2021; 3 (01) 45
  • 4 Warren JA, Sundaram K, Anis HK, Kamath AF, Higuera CA, Piuzzi NS. Have venous thromboembolism rates decreased in total hip and knee arthroplasty?. J Arthroplasty 2020; 35 (01) 259-264
  • 5 Santana DC, Hadad MJ, Emara A. et al. Perioperative management of chronic antithrombotic agents in elective hip and knee arthroplasty. Medicina (Kaunas) 2021; 57 (02) 188
  • 6 Flevas DA, Megaloikonomos PD, Dimopoulos L, Mitsiokapa E, Koulouvaris P, Mavrogenis AF. Thromboembolism prophylaxis in orthopaedics: an update. EFORT Open Rev 2018; 3 (04) 136-148
  • 7 Acuña AJ, Grits D, Samuel LT, Emara AK, Kamath AF. Perioperative blood transfusions are associated with a higher incidence of thromboembolic events after TKA: an analysis of 333,463 TKAs. Clin Orthop Relat Res 2021; 479 (03) 589-600
  • 8 Sloan M, Sheth N, Lee G-C. Is obesity associated with increased risk of deep vein thrombosis or pulmonary embolism after hip and knee arthroplasty? A large database study. Clin Orthop Relat Res 2019; 477 (03) 523-532
  • 9 Liu L, Liu H, Zhang H, Song J, Zhang L. Bilateral total knee arthroplasty: simultaneous or staged? A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98 (22) e15931
  • 10 Kuperman EF, Schweizer M, Joy P, Gu X, Fang MM. The effects of advanced age on primary total knee arthroplasty: a meta-analysis and systematic review. BMC Geriatr 2016; 16: 41
  • 11 Shen M, Cutrera NJ, Dodd AC. et al. The risk of deep vein thrombosis in total joint patients compared to orthopaedic trauma patients: need for new prevention guidelines. J Clin Orthop Trauma 2017; 8 (Suppl. 02) S52-S56
  • 12 Zhang J, Chen Z, Zheng J, Breusch SJ, Tian J. Risk factors for venous thromboembolism after total hip and total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2015; 135 (06) 759-772
  • 13 Dai W-L, Lin Z-M, Shi Z-J, Wang J. Venous thromboembolic events after total knee arthroplasty: which patients are at a high risk?. J Knee Surg 2020; 33 (10) 947-957
  • 14 Khera R, Angraal S, Couch T. et al. Adherence to methodological standards in research using the national inpatient sample. JAMA 2017; 318 (20) 2011-2018
  • 15 Steiner C, Elixhauser A, Schnaier J. The healthcare cost and utilization project: an overview. Eff Clin Pract 2002; 5 (03) 143-151
  • 16 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 2014; 12 (12) 1495-1499
  • 17 Bewick V, Cheek L, Ball J. Statistics review 8: qualitative data - tests of association. Crit Care 2004; 8 (01) 46-53
  • 18 Armstrong RA. When to use the Bonferroni correction. Ophthalmic Physiol Opt 2014; 34 (05) 502-508
  • 19 Hidalgo B, Goodman M. Multivariate or multivariable regression?. Am J Public Health 2013; 103 (01) 39-40
  • 20 Keller K, Hobohm L, Barco S. et al. Venous thromboembolism in patients hospitalized for knee joint replacement surgery. Sci Rep 2020; 10 (01) 22440
  • 21 White RH, Henderson MC. Risk factors for venous thromboembolism after total hip and knee replacement surgery. Curr Opin Pulm Med 2002; 8 (05) 365-371
  • 22 Lu Y, Zhou Z-Y, Liu Y-K, Chen H-L, Yang H-L, Liu F. Gender differences of venous thromboembolism risk after total hip and total knee arthroplasty: a meta-analysis. J Thromb Thrombolysis 2016; 41 (04) 556-562
  • 23 Olson JJ, Schwab P-E, Jackson J, Lange JK, Bedair HS, Abdeen A. HIV-positive patients are at increased risk of venous thromboembolism after total joint replacement. J Am Acad Orthop Surg 2021; 29 (11) 479-485
  • 24 Thomas RH. Hypercoagulability syndromes. Arch Intern Med 2001; 161 (20) 2433-2439
  • 25 Chew HK, Wun T, Harvey D, Zhou H, White RH. Incidence of venous thromboembolism and its effect on survival among patients with common cancers. Arch Intern Med 2006; 166 (04) 458-464
  • 26 Parvizi J, Huang R, Rezapoor M, Bagheri B, Maltenfort MG. Individualized risk model for venous thromboembolism after total joint arthroplasty. J Arthroplasty 2016; 31 (Suppl. 09) 180-186
  • 27 Lassen MR, Borris LC, Nakov RL. Use of the low-molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization. N Engl J Med 2002; 347 (10) 726-730
  • 28 Bates SM, Ginsberg JS. Clinical practice. Treatment of deep-vein thrombosis. N Engl J Med 2004; 351 (03) 268-277
  • 29 Kelly J, Rudd A, Lewis R, Hunt BJ. Venous thromboembolism after acute stroke. Stroke 2001; 32 (01) 262-267
  • 30 Temraz S, Tamim H, Mailhac A, Taher A. Could sodium imbalances predispose to postoperative venous thromboembolism? An analysis of the NSQIP database. Thromb J 2018; 16 (01) 11
  • 31 Livesey JA, Manning RA, Meek JH. et al. Low serum iron levels are associated with elevated plasma levels of coagulation factor VIII and pulmonary emboli/deep venous thromboses in replicate cohorts of patients with hereditary haemorrhagic telangiectasia. Thorax 2012; 67 (04) 328-333
  • 32 Hood BR, Cowen ME, Zheng HT, Hughes RE, Singal B, Hallstrom BR. Association of aspirin with prevention of venous thromboembolism in patients after total knee arthroplasty compared with other anticoagulants: a noninferiority analysis. JAMA Surg 2019; 154 (01) 65-72
  • 33 Matharu GS, Kunutsor SK, Judge A, Blom AW, Whitehouse MR. Clinical effectiveness and safety of aspirin for venous thromboembolism prophylaxis after total hip and knee replacement: a systematic review and meta-analysis of randomized clinical trials. JAMA Intern Med 2020; 180 (03) 376-384
  • 34 Mula V, Parikh S, Suresh S, Bottle A, Loeffler M, Alam M. Venous thromboembolism rates after hip and knee arthroplasty and hip fractures. BMC Musculoskelet Disord 2020; 21 (01) 95
  • 35 Tay K, Bin Abd Razak HR, Tan AHC. Obesity and venous thromboembolism in total knee arthroplasty patients in an Asian population. J Arthroplasty 2016; 31 (12) 2880-2883