James D. Slover, M.D.

Cost-effectiveness analysis of custom total knee cutting blocks
Slover, James D; Rubash, Harry E; Malchau, Henrik; Bosco, Joseph A
2012 Feb;27(2):180-185, Journal of arthroplasty
The purposes of this study were to examine the cost-effectiveness of this technology and to determine improvements in patient outcome needed to make custom total knee cutting blocks cost-effective. A Markov decision model was used to evaluate the cost-effectiveness of custom cutting blocks compared with traditional instrumentation in total knee arthroplasty. The analysis demonstrates routine use of custom cutting blocks for total knee arthroplasty will not be cost-effective unless it results in a significantly reduced revision rate. The reduction necessary increases with increasing costs for the custom blocks. Further research will be necessary to determine if this can be achieved using custom cutting blocks. Patients, surgeons, payers, and institutions should consider this when determining their support of this technology in the absence of supportive data
— id: 149940, year: 2012, vol: 27, page: 180, stat: Journal Article,

Health state utility in patients with osteoarthritis of the hip and total hip arthroplasty
Bozic, Kevin J; Chiu, Vanessa W; Slover, James D; Immerman, Igor; Kahn, James G
2011 Sep;26(6 Suppl):129-132.e1, Journal of arthroplasty
Understanding patients' perceived health status, as measured by health state utility, is important when evaluating the societal impact of hip osteoarthritis (OA) and total hip arthroplasty (THA). The purpose of this study was to measure health state utility in patients with hip OA and THA. A total of 231 patients from 2 institutions were enrolled into 1 of 6 cohorts: chronic hip OA, successful and failed primary THA, successful and failed revision THA, and infected THA. Average health state utilities were calculated using the time-trade-off method. Health state utilities were highest for primary THA (0.96) and lowest for infected THA (0.46). Our data demonstrate that THA results in substantial improvement in perceived health status in patients with chronic hip OA. However, health state utility is significantly worse after revision THA than primary THA, and failed primary or revision THA results in substantially reduced health state utility, similar to or worse than chronic OA
— id: 137959, year: 2011, vol: 26, page: 129, stat: Journal Article,

Is repetitive intraoperative splash basin use a source of bacterial contamination in total joint replacement?
Glait, Sergio A; Schwarzkopf, Ran; Gould, Steven; Bosco, Joseph; Slover, James
2011 Sep;34(9):e546-e549, Orthopedics (Thorofare NJ)
Splash basins are used in arthroplasty cases to wash instruments. Several studies in the literature have shown these basins being a potential source of bacterial infection. This study assesses the risk of contamination of intraoperative splash basins used to wash and store instruments. A total of 46 random clean primary arthroplasty cases (32 hips, 13 knees, and 1 unicondylar knee) were studied by taking cultures of sterile splash basins as soon as they are opened (controls) and again at wound closure after instruments and debris have come into contact with the sterile water. All cultures were taken with sterile culture swabs and sent to the laboratory for aerobic, anaerobic, and fungal culture. Outcome measured was any positive culture. A total of 92 cultures from 46 cases were tested. Only 1 (2.17%) control culture, which grew Streptococcus viridans, was positive for bacterial growth. One of 46 samples (2.17%) taken at wound closure was positive for coagulase-negative Staphylococcus. Mean time between basin opening and wound closure was 180+/-45 minutes. For the 1 infected sample taken at the conclusion of the case, it was 240 minutes. Previous studies show contamination rates as high as 74% for splash basins used intraoperatively. Our study contradicts the belief that splash basins are a high source of infection, with only 2.17% of basins showing contamination. Splash basins can be a potential source of contamination, but the risk is not as high as previously cited in the orthopedic literature
— id: 139475, year: 2011, vol: 34, page: e546, stat: Journal Article,

Blood, bugs, and motion - what do we really know in regard to total joint arthroplasty?
Glassner, Philip J; Slover, James D; Bosco, Joseph A 3rd; Zuckerman, Joseph D
2011 ;69(1):73-80, Bulletin of the NYU Hospital for Joint Diseases
In total joint arthroplasty, it is often necessary to formulate decisions that are not clearly evidence-based. This review presents some current controversial topics in total joint arthroplasty, including preoperative autologous blood donation versus erythropoietin (EPO) usage, preoperative screening and treatment for methicillin resistant Staphylococcus aureus (MRSA), and the use of continuous passive motion (CPM) following total knee arthroplasty, providing an evidence-based guide for the treating orthopaedic surgeon. Our review shows that preoperative autologous blood donation is over utilized, with EPO being under utilized. Surgeons are encouraged to develop patient-specific strategies, which have been shown to decrease transfusion rates, reduce wasted autologous blood, and increase EPO use. Definitive conclusions regarding MRSA screening for orthopaedic patients cannot be drawn; but due to the significant cost and morbidity associated with a postoperative MRSA infection, we believe a screen and treat protocol should be considered for all patients being admitted to the hospital for elective or emergent surgery. Short-term (3 to 5 days) inpatient use of CPM is recommended at this time. It is low-cost, has minimal risk, and may be a factor in decreasing the length of stay, potentially leading to significant cost savings. However, no long-term benefits of CPM use have been established
— id: 128798, year: 2011, vol: 69, page: 73, stat: Journal Article,

Breakout session: Ethnic and racial disparities in joint arthroplasty
Morgan, Randall C Jr; Slover, James
2011 Jul;469(7):1886-1890, Clinical orthopaedics & related research
BACKGROUND: Many authors report racial and ethnic disparities in total joint arthroplasty. The extent and implications, however, are not fully understood. QUESTIONS/PURPOSES: Our purposes in this breakout session were to (1) define 'Where are we now?'; (2) outline 'Where do we need to go?'; and (3) generate a plan for 'How do we get there?' in addressing issues of racial disparity and total joint arthroplasty. WHERE ARE WE NOW?: Blacks and some other ethnic minorities have a greater incidence of arthritis and chronic disability than the population in general. Blacks have a lower use of total joint arthroplasty for a variety of reasons, including patient trust, perceived limited satisfaction with results by peers, varying knowledge about total joint arthroplasty, and concerns about pain associated with these procedures. Current data, however, are insufficient to clearly define the magnitude and nature of musculoskeletal disparities. WHERE DO WE NEED TO GO?: We need to better define the magnitude and nature of racial disparities to best design and implement research questions and studies and target areas for improvement. We should define geographic and provider variation that lead to the differences in use that has been observed in total joint arthroplasty. HOW DO WE GET THERE?: A profession-wide emphasis and focus on disparities needs to be developed with other medical specialties and national organizations to advocate for changes to better define and address racial disparities. Partnerships with organizations and/or investigators that can gain access to relevant databases should be encouraged. Special attention to disparities and manuscript reviewing and editing is essential
— id: 137990, year: 2011, vol: 469, page: 1886, stat: Journal Article,

Correlation between nutritional status and staphylococcus colonization in hip and knee replacement patients
Schwarzkopf R.; Russell T.A.; Shea M.; Slover J.D.
2011 ;69(4):308-311, Bulletin of the NYU Hospital for Joint Diseases
Orthopaedic patients with poor nutritional status are at an increased risk of postoperative complications, such as infection and wound healing. Nasal colonization with Staphylococcus aureus, especially with methicillin-resistant Staphylococcus aureus, has been shown to be a risk factor for surgical-site infections. We examined the incidence of nutritional depletion in our arthroplasty population and its correlation with Staphylococcus aureus colonization. We conducted a retrospective review of prospectively collected data of our arthroplasty patient population. Patients with known Staphylococcus aureus colonization or surgical-site infection were compared with a random cohort of patients. Patient demographics, preoperative nasal culture, and two nutritional screening scores were collected. Six hundred and fifty-two patients underwent arthroplasty and completed preoperative nasal cultures and nutritional assessment. A high percentage (27%) of our patients demonstrated some level of nutritional depletion prior to joint replacement. Overall nutritional scores were not significantly associated with surgery-type, preoperative nasal culture, or surgicalsite infection in our patient population
— id: 148751, year: 2011, vol: 69, page: 308, stat: Journal Article,

Postoperative Complication Rates in the "Super-Obese" Hip and Knee Arthroplasty Population
Schwarzkopf R; Thompson SL; Adwar SJ; Liublinska V; Slover JD
2011 Jun 13;:?-? #, Journal of arthroplasty
The effect of obesity on the outcomes of total joint arthroplasties is an ongoing concern. As obesity becomes more endemic, new categories emerge, such as the 'super-obese.' We conducted a retrospective study to determine the difference in outcomes among the super-obese. When categorized according to body mass index (BMI), the overall rate of complications was higher for patients with BMI of 45 or higher. Super-obese patients had an odds ratio (OR) of 8.44 for developing inhospital complications. Most importantly, each incremental 5-U increase in BMI above 45 was associated with an increased risk of inhospital (OR, 1.69) and outpatient complications (OR, 2.71), and readmission (OR, 2.0), compared with patients with BMI of 45 to 50. Length of stay was increased by 13.8% for each 5-U increase in BMI above 45. There is a significant increased risk for complications in the super-obese population, and this continues to increase with BMI increases above 45. These data are important when counseling super-obese patients and should be accounted for in reporting quality outcome measures in this population
— id: 138043, year: 2011, vol: , page: ?, stat: Journal Article,

Medical clearance risk rating as a predictor of perioperative complications after total hip arthroplasty
Schwarzkopf, Ran; Katz, Gregory; Walsh, Michael; Lafferty, Paul M; Slover, James D
2011 Jan;26(1):36-40, Journal of arthroplasty
Hip arthroplasty has become the standard treatment of end-stage osteoarthritis. However, postoperative complications are the risks associated with joint arthroplasty, which most significantly impact patient results and the total cost of care. Currently, no predictive system has been developed for categorizing levels of risk for the development of postoperative complications in patients undergoing total hip arthroplasty. We examined the association between the medical clearance risk rating by the physician performing the preoperative clearance examination and postoperative complications after total hip arthroplasty. We have demonstrated a significant association between the medical clearance risk rating and postoperative urinary track infection, and the American Society of Anesthesiologist score but no significant association to other complications. This study presents a predictive patient characteristic that may help us identify among our patients the ones that may benefit from a personally tailored preoperative planning and evaluation but demonstrates further work is necessary to better predict the risk of complications after total hip arthroplasty
— id: 117335, year: 2011, vol: 26, page: 36, stat: Journal Article,

Cost-effectiveness of a Staphylococcus aureus screening and decolonization program for high-risk orthopedic patients
Slover, James; Haas, Janet P; Quirno, Martin; Phillips, Michael S; Bosco, Joseph A 3rd
2011 Apr;26(3):360-365, Journal of arthroplasty
We conducted a Markov decision analysis to assess the cost savings associated with a preoperative Staphylococcus aureus screening and decolonization program on 365 hip and knee arthroplasties and 287 spine fusions. A 2-way sensitivity analysis was also used to calculate the needed reduction in surgical site infections to make the program cost saving. If cost of treating an infected hip or knee arthroplasty is equal to the cost of a primary knee arthroplasty, then the screening program needs to result in a 35% reduction in the revision rate, or a relative revision rate of 65% for patients in the screening program, to be cost saving. For spine fusions, the reduction in the revision rate to make the program cost saving is only 10%. Universal Staphylococcus aureus screening and decolonization for hip and knee arthroplasty and spinal fusion patients needs to result in only a modest reduction in the surgical site infection rate to be cost saving
— id: 132306, year: 2011, vol: 26, page: 360, stat: Journal Article,

Perioperative strategies for decreasing infection: a comprehensive evidence-based approach
Bosco, Joseph A 3rd; Slover, James D; Haas, Janet P
2010 Jan;92(1):232-239, Journal of bone & joint surgery (American volume)
— id: 106103, year: 2010, vol: 92, page: 232, stat: Journal Article,

Perioperative strategies for decreasing infection: a comprehensive evidence-based approach
Bosco, Joseph A 3rd; Slover, James D; Haas, Janet P
2010 ;59:619-628, Instructional course lectures (American Association of Orthopaedic Surgeons)
Surgical site infections are a devastating complication of orthopaedic procedures and result in increased morbidity and mortality as well as higher costs. Universally, patients with surgical site infections have a worse outcome than uninfected patients. Payers of health care and regulatory organizations, such as the Centers for Medicare and Medicaid Services and the Joint Commission, are demanding both accountability and a reduction in the occurrence of surgical site infections. To effectively prevent such infections, the clinician must address preoperative, intraoperative, and postoperative factors, along with interventions. In the areas where evidence-based literature demonstrates a clear best practice, such as prophylactic antibiotic use and surgical scrub techniques, physicians and health care professionals will be held accountable for compliance with these standards. This accountability will be quantified and will be made available to the public. It is also evident that payers will reward and/or penalize physicians for failure to comply with established standards of care. For the health and safety of patients, surgeons are obligated to become familiar with the known best practices and standards of care with respect to the reduction of surgical site infections
— id: 109519, year: 2010, vol: 59, page: 619, stat: Journal Article,

Athletic participation after hip and knee arthroplasty
Golant, Alexander; Christoforou, Dimitrios C; Slover, James D; Zuckerman, Joseph D
2010 ;68(2):76-83, Bulletin of the NYU Hospital for Joint Diseases
The issue of athletic participation after hip and knee arthroplasty has become more relevant in recent years, with an increase in the number of young and active patients receiving joint replacements. This article reviews patient-, surgery-, implant-, and sports-related factors, and discusses currently available guidelines that should be considered by the physician when counseling patients regarding a return to athletic activity after total joint arthroplasty. Current evidence regarding appropriate athletic participation after total hip arthroplasty, resurfacing hip arthroplasty, total knee arthroplasty, and unicondylar knee arthroplasty is reviewed
— id: 111377, year: 2010, vol: 68, page: 76, stat: Journal Article,

Staphylococcus aureus Decolonization Protocol Decreases Surgical Site Infections for Total Joint Replacement
Hadley, Scott; Immerman, Igor; Hutzler, Lorraine; Slover, James; Bosco, Joseph
2010 ;2010:924518-924518, Arthritis
We investigated the effects of implementation of an institution-wide screening and decolonization protocol on the rates of deep surgical site infections (SSIs) in patients undergoing primary knee and hip arthroplasties. 2058 patients were enrolled in this study: 1644 patients in the treatment group and 414 in the control group. The treatment group attended preoperative admission testing (PAT) clinic where they were screened for MSSA and MRSA colonization. All patients were provided a 5-day course of nasal mupirocin and a single preoperative chlorhexidine shower. Additionally, patients colonized with MRSA received Vancomycin perioperative prophylaxis. The control group did not attend PAT nor receive mupirocin treatment and received either Ancef or Clindamycin for perioperative antibiotic prophylaxis. There were a total of 6 deep infections in the control group (1.45%) and 21 in the treatment group (1.28%); this represented a decrease of 13% (P = .809) in the treatment versus control group. This decrease represented a positive trend in favor of staphylococcus screening, decolonization with mupirocin, and perioperative Vancomycin for known MRSA carriers
— id: 140540, year: 2010, vol: 2010, page: 924518, stat: Journal Article,

Recurrent hemarthrosis in a hemophilic patient after revision total knee arthroplasty
Park, Justin J; Slover, James D; Stuchin, Steven A
2010 Oct;33(10):771-771, Orthopedics (Thorofare NJ)
Recurrent hemarthrosis following a revision total knee arthroplasty is a rare complication. The likelihood of encountering bleeding complications in patients with hemophilia C following major surgery is unpredictable. Although the use of postoperative chemotherapeutic agents to prevent deep venous thrombosis (DVT) is considered the standard of care for most patients, its use in the hemophiliac population is unknown. This case describes a woman with Hemophilia C who presented with recurrent hemarthrosis 9 days after her revision total knee arthroplasty. Initial treatment efforts were directed towards treating the patient's underlying coagulopathy. Repeated transfusions of fresh frozen plasma and desmopressin were given in an attempt to achieve hemostasis. However the hemarthrosis did not resolve and 36 days postoperatively, a pseudoaneurysm of the left superior geniculate artery was found by angiography and percutaneously embolized. This article presents the first case, to our knowledge, of recurrent hemarthrosis in a hemophiliac patient after revision total knee arthroplasty. It further highlights the importance of considering all possible causes of postoperative bleeding to make a timely diagnosis in the face of a confounding clinical picture
— id: 129373, year: 2010, vol: 33, page: 771, stat: Journal Article,

Prevalence of Staphylococcus aureus Colonization in Orthopaedic Surgeons and Their Patients: A Prospective Cohort Controlled Study
Schwarzkopf, Ran; Takemoto, Richelle C; Immerman, Igor; Slover, James D; Bosco, Joseph A
2010 Sep;92(9):1815-1819, Journal of bone & joint surgery (American volume)
BACKGROUND: Methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus surgical site infections are an increasing health problem in the United States. To date, no study, as far as we know, has evaluated the prevalence of Staphylococcus aureus colonization in orthopaedic surgeons. The purpose of our study was to assess the prevalence of methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus colonization in orthopaedic surgery attending surgeons and residents at our institution compared with that in our high-risk patients. METHODS: We performed nasal swab cultures in seventy-four orthopaedic attending surgeons and sixty-one orthopaedic surgery residents at our institution, screening for methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus. We compared these results with a prospective database of nasal cultures of patients undergoing joint replacement and spine surgery. RESULTS: A total of 135 physicians were screened. Of those physicians, 1.5% were positive for methicillin-resistant Staphylococcus aureus and 35.7% were positive for methicillin-sensitive Staphylococcus aureus. None of the sixty-one residents were positive for methicillin-resistant Staphylococcus aureus. However, 59% were positive for methicillin-sensitive Staphylococcus aureus. Of the seventy-four attending surgeons, 2.7% were positive for methicillin-resistant Staphylococcus aureus and 23.3%, for methicillin-sensitive Staphylococcus aureus. Previous studies at our institution have demonstrated a 2.17% prevalence of nasal carriage of methicillin-resistant Staphylococcus aureus and an 18% rate of methicillin-sensitive Staphylococcus aureus in high-risk patients. Thus, no difference was found between the prevalence of methicillin-resistant Staphylococcus aureus in residents or attending surgeons and that in the high-risk patients. However, the prevalence of methicillin-sensitive Staphylococcus aureus colonization in the surgeons (35.7%) was significantly higher than that in the high-risk patient group (18%) (p < 0.01). CONCLUSIONS: At a major teaching hospital, a higher prevalence of methicillin-sensitive Staphylococcus aureus colonization was found among attending and resident orthopaedic surgeons compared with a high-risk patient group, but the prevalence of methicillin-resistant Staphylococcus aureus colonization was similar
— id: 111540, year: 2010, vol: 92, page: 1815, stat: Journal Article,

Sex and race characteristics in patients undergoing hip and knee arthroplasty in an urban setting
Slover, James D; Walsh, Michael G; Zuckerman, Joseph D
2010 Jun;25(4):576-580, Journal of arthroplasty
The purpose of this study was to examine the relationship between sex, race, and preoperative function in a large diverse patient population undergoing hip and knee arthroplasty. An observational study was conducted on 3542 consecutive primary unilateral total hip and knee arthroplasties. Harris Hip and Knee Society Scores were used to quantify preoperative function. The results demonstrate lower function, with average Harris Hip Scores that were 4.9 (P < .0001) and 8.77 (P < .001) and average Knee Society Scores that were 6.03 (P < .06) and 12.8 (P < .001) points lower in African American and Hispanic patients than white patients for the population, respectively. This study demonstrates that Hispanic and African American patients have worse preoperative hip and knee function before arthroplasty than white patients. Future efforts to elucidate the reasons for this decreased function as well as efforts to rectify any disparities should target these patient populations
— id: 109784, year: 2010, vol: 25, page: 576, stat: Journal Article,

A cost-effectiveness analysis of the arthroplasty options for displaced femoral neck fractures in the active, healthy, elderly population
Slover, James; Hoffman, Michael V; Malchau, Henrik; Tosteson, Anna N A; Koval, Kenneth J
2009 Sep;24(6):854-860, Journal of arthroplasty
This study was performed to explore the cost-effectiveness of total hip arthroplasty (THA) compared with hemiarthroplasty (HEMI) in the treatment of displaced femoral neck fractures in active otherwise healthy older patients in whom the optimum treatment is believed to be an arthroplasty procedure. A Markov decision model was used to determine whether THA or HEMI was most cost-effective for the management of a displaced femoral neck fracture in this patient population. Total hip arthroplasty was associated with an average cost $3000 more than HEMI, and the average quality-adjusted life year gain was 1.53. The incremental cost-effectiveness ratio associated with the THA treatment strategy is $1960 per quality-adjusted life year. Currently available data support the use of THA as the more cost-effective treatment strategy in this specific population. The increased upfront cost appears to be offset by the improved functional results when compared with HEMI in this select patient group
— id: 115394, year: 2009, vol: 24, page: 854, stat: Journal Article,

ETHNIC DISPARITIES IN ADVANCED END-STAGE OSTEOARTHRITIS
Walsh, MG; Slover, J; DiCesare, PE
2009 JUN 1 ;169(12):S96-S96, American journal of epidemiology
— id: 100452, year: 2009, vol: 169, page: S96, stat: Journal Article,

Hip resurfacing arthroplasty: time to consider it again? No
Slover, James D; Rubash, Harry E
2008 ;57:267-271, Instructional course lectures (American Association of Orthopaedic Surgeons)
Total hip arthroplasty (THA) is one of the most successful operations in orthopaedics. A new procedure designed to replace THA, such as hip resurfacing arthroplasty, even for select indications, must offer a definite improvement over the well-established gold standard of treatment. Hip resurfacing does not currently meet this standard. THA is a proven and durable procedure with excellent results and superior short-term implant survival compared with hip resurfacing arthroplasty. Patients treated with hip resurfacing arthroplasty incur unique risks associated with implant malpositioning resulting from the surgeons' steep learning curve, the complex instrumentation involved, and the technical difficulty of the procedure, as well as a risk of femoral neck fracture. Hip resurfacing has limited ability to appropriately restore hip biomechanics and limb length, and concerns for the effects of metal ion and potential revision challenges remain. To date, there is a lack of literature supporting the claim of superior functional outcomes in hip resurfacing compared with THA. Reconsideration of hip resurfacing arthroplasty is unwarranted until appropriate comparative studies can demonstrate a clear benefit to patients
— id: 94802, year: 2008, vol: 57, page: 267, stat: Journal Article,

Impact of hospital volume on the economic value of computer navigation for total knee replacement
Slover, James D; Tosteson, Anna N A; Bozic, Kevin J; Rubash, Harry E; Malchau, Henrik
2008 Jul;90(7):1492-1500, Journal of bone & joint surgery (American volume)
BACKGROUND: An aim of the use of computer navigation is to reduce rates of revisions of total knee replacements by improving the alignment achieved at the surgery. However, the decision to adopt this technology may be difficult for some centers, especially low-volume centers, where the cost of purchasing this equipment may be high. The purpose of this study was to examine the impact of hospital volume on the cost-effectiveness of this new technology in order to determine its feasibility and the level of evidence that should be sought prior to its adoption. METHODS: A Markov decision model was used to evaluate the impact of hospital volume on the cost-effectiveness of computer-assisted knee arthroplasty in a theoretical cohort of sixty-five-year-old patients with end-stage arthritis of the knee to coincide with the peak incidence of knee arthroplasty in the United States. RESULTS: Computer-assisted surgery becomes less cost-effective as the annual hospital volume decreases, as the cost of the navigation increases, and as the impact on revision rates decreases. Centers at which 250, 150, and twenty-five computer-navigated total knee arthroplasties are performed per year will require a reduction of the annual revision rate of 2%, 2.5%, and 13%, respectively, per year over a twenty-year period for computer navigation to be cost-effective. CONCLUSIONS: Computer navigation is less likely to be a cost-effective investment in health-care improvement in centers with a low volume of joint replacements, where its benefit is most likely to be realized. However, it may be a cost-effective technology for centers with a higher volume of joint replacements, where the decrease in the rate of knee revision needed to make the investment cost-effective is modest, if improvements in revision rates with the use of this technology can be realized
— id: 80285, year: 2008, vol: 90, page: 1492, stat: Journal Article,

Can condition-specific health surveys be specific to spine disease? An analysis of the effect of comorbidities on baseline condition-specific and general health survey scores
Slover, James; Abdu, William A; Hanscom, Brett; Lurie, Jon; Weinstein, James N
2006 May 15;31(11):1265-1271, Spine
STUDY DESIGN: This is an observational cross-sectional study of 26,290 patients seen and evaluated in the 25 centers of the National Spine Network. OBJECTIVE: To explore the correlation between medical and psychosocial comorbidities, and baseline Short-Form 36 Health Status questionnaire (SF-36) and Oswestry Disability Index (ODI) (Musculoskeletal Outcomes Data Evaluation and Management Systems version with scales reversed so that a score of 100 represents no disability, and a score of 0 represents severe disability) scores in spine patients. SUMMARY OF BACKGROUND DATA: It remains unclear whether general health questionnaires or condition-specific surveys are superior for evaluating spine patients (Spine 2000;25:3100-3). Most clinicians would suspect that comorbidities (medical and psychosocial) play a significant role in the presentation, treatment, and outcome of spine patients. Yet, it has been difficult to quantify specifically the association of comorbidities with traditional health status instrument scores for spine patients. METHODS: Initial visit (baseline) health questionnaires were analyzed. Patients were stratified according to the number of self-reported comorbidities. Analysis of variance was performed to assess the difference in mean health status across comorbidity groups. Multiple linear regressions were used to identify the most influential individual comorbidities on baseline functional survey scores. RESULTS: There is an associated decrease in baseline physical component summary (PCS) (from the SF-36) and ODI scores with the addition of each comorbidity. For the range of zero to > or =7 comorbidities, the PCS score decreases from 33.3 to 23.2 (P < 0.001). The average baseline ODI score for patients with zero comorbidities was 62.4, decreasing to 42.0 in the group with > or =7 comorbidities (P < 0.001). The strongest association was seen with the medical comorbidities of smoking, frequent headaches, osteoarthritis, and osteoporosis (P < 0.001). However, the association with psychosocial comorbidities(e.g., self-rated health, active compensation case, depression) (P < 0.001) was higher for both health status measures. Health status measures in patients with lumbar problems show that these patients are more impacted by their disease than patients with cervical or thoracic spine problems (P < 0.001), although the correlation with comorbidities is smaller for the lumbar group (P < 0.001). CONCLUSION: Traditional medical comorbidities correlate with both SF-36 (e.g., PCS) general health survey scores as well as disease-specific ODI scores. However, psychosocial comorbidities such as poor self-rated health (SF-1), an active compensation case, and low education level have a higher association than traditional medical comorbidities on these health status measures. The results show that the type of survey (disease-specific e.g., ODI, vs. generic e.g., SF-36) used may be less important than the need to assess and control for psychosocial and medical comorbidities when any patient-reported health survey is used in the spine population.
— id: 72826, year: 2006, vol: 31, page: 1265, stat: Journal Article,

The impact of comorbidities on the change in short-form 36 and oswestry scores following lumbar spine surgery
Slover, James; Abdu, William A; Hanscom, Brett; Weinstein, James N
2006 Aug 1;31(17):1974-1980, Spine
STUDY DESIGN: This is an observational study of 3482 patients undergoing lumbar spine surgery from the National Spine Network. OBJECTIVES: To explore the influence of medical and psychosocial comorbidities on the change in Short-form 36 (SF-36) general health survey and condition-specific Oswestry Disability Index (ODI) scores in patients undergoing lumbar spine surgery. SUMMARY OF BACKGROUND DATA: It remains unclear as to which type of health instrument is more appropriate for monitoring improvement in patients who undergo lumbar spine surgery. Most clinicians would suspect that comorbidities (medical and psychosocial) play a significant role in the outcome of spine patients. Yet, it has been difficult to quantify specifically the impact of comorbidities on the responsiveness of traditional health status instruments for spine patients. METHODS: Analysis of variance was performed to assess the difference in the change in survey scores across comorbidity groups for the population of National Spine Network patients who had undergone lumbar spine surgical intervention and completed 3-month and 1-year follow-up surveys. Multiple linear regressions were used to identify the most influential individual comorbidities on the change scores. RESULTS: Comorbidities had a significant impact on the change in scores at 3 months and 1 year. The average change in bodily pain, physical function, physical component summary scores of the SF-36, as well as ODI scores decreased in response to surgery as the number of comorbidities increased. Psychosocial comorbidities such as an active compensation case, self-rated poor health, and smoking exerted large effects on the change in survey scores after surgery (P < 0.003). Medical disorders such as headaches, depression, and nervous system disorders were also highly influential (P < 0.05). CONCLUSIONS: The negative impact of medical and psychosocial comorbidities on the change in SF-36 general health survey and condition-specific ODI scores, despite spine surgery, highlights the need for researchers and clinicians to consider these comorbidities when using these, and perhaps all, health survey instruments and interpreting these scores after surgery. Contrary to current assumptions regarding condition-specific health surveys, medical and psychosocial comorbidities similarly affect the generic SF-36 and condition-specific ODI. Further studiesare needed to determine if spine surgery outcomes can be improved by specifically addressing potentially modifiable comorbidities, which negatively impact survey scores, or whether comorbidity burden should play a role in the selection process for surgical intervention. Failure to incorporate consideration of medical and psychosocial comorbidities into preoperative discussions can be a failure to allow our patients (and ourselves) to have realistic expectations and, consequently, the best possible outcome from their treatment choice.
— id: 72825, year: 2006, vol: 31, page: 1974, stat: Journal Article,

Cost-effectiveness of unicompartmental and total knee arthroplasty in elderly low-demand patients. A Markov decision analysis
Slover, James; Espehaug, Birgitte; Havelin, Leif Ivar; Engesaeter, Lars Birger; Furnes, Ove; Tomek, Ivan; Tosteson, Anna
2006 Nov;88(11):2348-2355, Journal of bone & joint surgery (American volume)
BACKGROUND: Interest in unicompartmental knee arthroplasty has recently increased in the United States, making a firm understanding of the indications for this procedure important. The purpose of this study was to examine the cost-effectiveness of unicompartmental knee arthroplasty compared with total knee arthroplasty in elderly low-demand patients. METHODS: A Markov decision model was used to evaluate the cost-effectiveness of unicompartmental knee arthroplasty as compared with total knee arthroplasty in the elderly population. Transition probabilities were estimated from the Norwegian Arthroplasty Register and the arthroplasty literature, and costs were based on the average Medicare reimbursement for unicompartmental, tricompartmental, and revision knee arthroplasties. Outcomes were measured in quality-adjusted life-years. RESULTS: Our model showed unicompartmental knee arthroplasty to be a cost-effective strategy for this population as long as the annual probability of revision is <4%. The cost of unicompartmental knee arthroplasty must be greater than $13,500 or the cost of total knee arthroplasty must be less than $8500 before total knee arthroplasty becomes more cost-effective. CONCLUSIONS: Our model suggests that, on the basis of currently available cost and outcomes data, unicompartmental knee arthroplasty and total knee arthroplasty have similar cost-effectiveness profiles in the elderly low-demand patient population. However, several important parameters that could alter the cost-effectiveness analysis were identified; these included implant survival rates, costs, perioperative mortality and infection rates, and utility values achieved with each procedure. The thresholds identified in this study may help decision-makers to evaluate the cost-effectiveness of each strategy as further research characterizes the variables associate with unicompartmental and total knee arthroplasties and may be helpful for designing future appropriate clinical trials.
— id: 72824, year: 2006, vol: 88, page: 2348, stat: Journal Article,

Racial and economic disparity and the treatment of pediatric fractures
Slover, James; Gibson, Jennifer; Tosteson, Tor; Smith, Brian; Koval, Kenneth
2005 Nov-Dec;25(6):717-721, Journal of pediatric orthopedics
Disparity in the treatment of various medical conditions in patient groups with differing racial and economic backgrounds has increasingly been reported. This paper examines the relationship between baseline racial and economic factors and the treatment of pediatric long-bone fractures. The 2000 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) was used to retrospectively examine the incidence and treatment of pediatric fractures. Data were included for supracondylar humerus (n = 2,957), femoral shaft (n = 1,726) or radius and ulna forearm fracture (n = 828) as their primary diagnosis were studied. Hispanic (78%) and black (82%) patients were more likely to receive closed reduction with internal fixation (percutaneous pinning) of supracondylar humerus fractures than whites (73%, P = 0.02). Despite a fairly large sample size, differences in treatment of supracondylar humerus fractures across primary payer or income groups were not statistically significant. Patients with femur fractures and private insurance were more likely to be treated with an external fixation device (7.2%) than patients in the Medicaid (3.8%) or self-pay (4.5%) groups (P = 0.015). No statistically significant difference was found in the treatment of forearm fractures across racial, primary payer or income groups. Racial and economic disparity is an important issue in medicine today. This study did demonstrate statistically significant differences in the treatment of pediatric supracondylar humerus across racial groups, with Blacks and Hispanics being more likely to receive percutaneous pinning of these injuries than Whites. Private insurance patients were also more likely to have femoral shaft fractures treated with an external fixator device than patients with Medicaid or self-pay as their primary payer. However, the clinical significance of these differences is not clear. Further research is needed to gain a more complete understanding of disparities in medicine, and their etiologies, in order to work towards optimizing the quality of medical care for all patient groups.
— id: 72827, year: 2005, vol: 25, page: 717, stat: Journal Article,