Greater Pittsburgh Orthopaedic Associates

Reducing hospital readmissions postspine surgery is crucial for improving care quality. Currently, no specific scoring system exists to stratify patients by readmission risk in spine surgery. The objective of this study was to evaluate risk factors for 30-day hospital readmission following elective decompressive spine surgery and develop an ML-based risk-scoring system. 653 patients undergoing elective decompressive spine surgery (with or without fusion) at a single academic center were retrospectively reviewed. Data collected included demographics, surgical details, preoperative admissions, and complications. Univariate logistic and Cox regression analyses identified significant predictors. A supervised ML-based risk scoring system was developed and compared against the institution's standard risk calculator. Of 653 patients, 44 (6.7%) experienced a 30-day readmission. Predictors of readmission included prior-year hospital admission, age-adjusted Charlson Comorbidity Index (CCI), traumatic or thoracic surgery, postoperative complications, and length of stay. An ML-based scoring system stratified patients into Low-risk (0-4 points; 2.16% readmission), Moderate-risk (5-9 points; 7.25%), High-risk (10-14 points; 21.57%), and Extreme-risk (15+ points; 39.47%) groups. Compared to the standard hospital score, the new model demonstrated superior performance: higher C-index (0.79 vs. 0.71), higher Somers' D (0.56 vs. 0.41), and lower Akaike Information Criterion (AIC) (516.78 vs. 546.65). Preoperative admission within 1 year prior to elective decompressive spine surgery significantly predicts 30-day readmission risk. Additional factors include age-adjusted CCI, traumatic or thoracic surgery, complications, and length of hospital stay. The proposed ML-based scoring system demonstrated superior predictive performance compared to the standard hospital readmission risk calculator, serving as a potentially valuable internal quality improvement tool pending external validation.

ABSTRACTBackgroundChronic low back pain (cLBP) is a multifactorial condition that can have various contributing factors, including biological, biomechanical, and behavioral. Recent evidence suggests that systemic inflammation may contribute to cLBP, impacting pain sensitivity and individuals' functional status. Circulatory pro‐ and anti‐inflammatory cytokines are widely used to determine individuals' systemic inflammatory status. The University of Pittsburgh Mechanistic Research Center, part of the National Institutes of Health's (NIH) Helping to End Addiction Long‐term Initiative, conducted a prospective, observational study to identify phenotypes in a large cohort of individuals with cLBP. The present work reports the quantification of key circulatory cytokines in this cLBP cohort.MethodsA total of 1007 individuals with cLBP were enrolled. Plasma samples were available from 936 participants, and concentrations of pro‐inflammatory (IL‐6, IFN‐γ, TNF, IL‐15, Leptin) and anti‐inflammatory (IL‐1ra, IL‐10) cytokines were measured via immunoassays. Pain and functional status were assessed using validated self‐reported numeric pain ratings scale and the Oswestry Disability Index. Descriptive statistics of analyzed cytokines were reported across the overall population, stratified by age (< 60 and ≥ 60 years old) and sex, and by pain levels as mild (0–5), moderate (6, 7), and severe (8–10), and ODI, categorized as minimal disability (0%–20%), moderate (21%–40%), and severe disability (> 40%).ResultsThe values of circulating cytokines assessed in this study aligned with those reported in the literature for other painful inflammatory conditions and, in most cases, exceeded those documented for healthy populations. IL‐6, IL‐1ra, and Leptin demonstrated higher concentrations with higher pain and disability severity. TNF showed higher concentration in participants with higher disability severity. Concentration levels of IFN‐γ, IL‐15, and IL‐10 exhibited no differences across pain or ODI categories. Notably, TNF levels were higher in older adults (≥ 60 years), whereas Leptin levels were higher in females than in males.ConclusionThis study provides a snapshot of key circulating cytokines in a large cLBP cohort, revealing differences in pro‐ and anti‐inflammatory cytokines across pain and disability for the overall population and in sex and age subgroups. Additional longitudinal and mechanistic studies are required to clarify how cytokines could serve as diagnostic, prognostic, or phenotyping markers, ultimately informing targeted, inflammation‐focused therapies that may reshape current treatment approaches.

ABSTRACTBackgroundChronic low back pain (cLBP) is complex, disabling, and costly to patients and to society. Patients' social circumstances, beliefs, and behaviors interact in a dynamic way with biomedical factors and have the potential to amplify or reduce suffering. It is important to assess the experience of pain via patient‐reported outcomes (PROs). The University of Pittsburgh Mechanistic Research Center, entitled, “Low Back Pain: Biological, Biomechanical, Behavioral Phenotypes (LB3P),” is part of the National Institutes of Health's Helping to End Addiction Long‐term Initiative. LB3P conducted a prospective, observational cohort study to identify phenotypes of over 1000 participants with cLBP. This article reports key information from the PROs and selected demographic variables obtained at the in‐person LB3P study enrollment visit.MethodsThe LB3P study participants completed numerous PROs, including the minimum data set assessments of the NIH Research Task Force on back pain and the NIH HEAL Initiative's Common Data Elements. PROs were organized into five conceptual domains: (1) Pain Characteristics and Qualities, (2) Pain‐related Psychosocial Factors, (3) General Psychosocial Factors, (4) General Health and Lifestyle Factors, and (5) Social Determinants of Health (SDoH). Patient Acceptance of Symptom Status, which consists of yes/no responses to 10 questions about whether the level of each of the 10 symptoms is satisfactory, was also assessed.ResultsPRO measures were collected from 1007 LB3P participants with cLBP. The means and standard deviations, or medians and interquartile ranges, and percentages for the PRO variables collected at the in‐person enrollment visit are presented for the overall group and stratified by sex at birth (females and males) and by age (< 60 years old and ≥ 60 years old). For the participants overall, and across sex and age groups, pain intensity and interference were moderate on average. Neuropathic pain, assessed via PainDETECT, was present in 18% of the overall sample, and in 22.5% of those younger than 60. On average, fatigue, depressive and anxiety symptoms, memory and concentration, self‐efficacy, and positive outlook were within normal limits, as indicated by PROMIS T‐scores. However, PROMIS Physical function was below normal, with T‐scores in the mild to moderate range of impairment. When participants were asked to rate the acceptability of their symptom status in 10 areas of function, the most frequently reported areas of dissatisfaction were: pain intensity and interference, physical function, sleep, and fatigue. In the area of SDoH, nearly half (44%) of participants reported having been exposed to traumatic experiences. In the overall group, 36% reported difficulty paying for basic needs such as food, medical care, and heating, while 51% of those in the < 60 group reported this level of financial strain.ConclusionsThe LB3P cLBP observational cohort exhibited moderate levels of pain intensity, pain interference with life activities, and pain‐related disability. Participants reported mild to moderate levels of pain‐related psychosocial factors, and general mental health challenges such as depression and anxiety were relatively rare. Many participants reported a history of exposure to traumatic experiences and having current financial challenges. The LB3P PRO results provide reference values for a community sample of persons with cLBP.

➢Glucagon-like peptide-1 (GLP-1) receptor agonists are a promising tool for preoperative weight loss in the patient who is undergoing orthopaedic surgery and has concomitant obesity and type-2 diabetes mellitus.➢With regard to the perioperative management of GLP-1 receptor agonists for the orthopaedic surgeon, the American Society of Anesthesiologists (ASA) recommends withholding daily-dose GLP-1 therapy on the day of the elective surgical procedure and withholding weekly-dose therapy for the week prior to the procedure.➢The ASA recommends postponing surgery or proceeding with “full stomach precautions” if the patient undergoing an orthopaedic procedure and taking GLP-1 therapy exhibits gastrointestinal symptoms on the day of the elective procedure.➢In the trauma setting, patients taking GLP-1 therapy should proceed with the surgical procedure at the discretion of the surgeon with full stomach precautions or a preoperative point-of-care gastric ultrasound.➢GLP-1 receptor agonists show the potential for disease modification in osteoarthritis and osteoporosis.

Patient experience scores are hospital-centric metrics, which are becoming increasingly important in healthcare quality assessment; however, the factors that influence these scores are poorly defined. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally administered, publicly reported patient experience survey that exerts a major influence on hospital reimbursement by the Centers for Medicare and Medicaid Services (CMS). The purpose of this study was to investigate the correlation between HCAHPS scores and postoperative patient-reported outcome measures (PROMs) up to 5 years after elective cervical and thoracolumbar spine surgery. All patients who had undergone elective spine surgery at a single academic tertiary center in 2010-2019 were potentially eligible for study inclusion. PROMs used in the study included the Neck Disability Index (NDI), Oswestry Disability Index (ODI), 10-Item Patient-Reported Outcomes Measurement Information System Global Health survey (PROMIS GH-10) global mental health (GMH) and global physical health (GPH) parameters, and patient acceptable symptom state for neck and back. Patients were excluded for surgical indications such as trauma, infection, or neoplasia or for missing PROM data. HCAHPS scores were collected from the electronic medical record and had been originally obtained via text message. Correlation analysis and longitudinal data analysis were used to assess relationships between PROMs and HCAHPS scores (α = 0.05). Three hundred ninety-seven patients with recorded PROMs were included in the study; 124 had undergone elective cervical surgery and 273 had undergone thoracolumbar surgery. HCAHPS scores showed small but significant correlations with NDI and the PROMIS GMH component 6 months after cervical surgery; however, no significant correlations were seen beyond 6 months. Additionally, there was no significant relationship between HCAHPS and postoperative PROMs following thoracolumbar surgery. Hospital experience scores, as assessed using the HCAHPS, show limited correlation with PROMs after elective spine surgery. While the HCAHPS currently plays a critical role for the CMS in determining hospital reimbursement rates, the study findings suggest that patient perceptions of inpatient care do not necessarily reflect their long-term functional outcomes. This result highlights the need for a multidimensional approach to evaluating healthcare quality, incorporating both short-term patient satisfaction and meaningful, enduring improvements in clinical outcomes.

Passive smartphone-based apps are becoming more common for measuring patient progress after total hip arthroplasty (THA). Optimum activity levels during early THA recovery have not been well documented. Correlations between step-count and patient reported outcome measures (PROMs) during early recovery were explored. This study also investigated how demographics impact step-count during early post-operative recovery. Smartphone captured step-count data from 666 THA patients was retrospectively reviewed. Mean age was 64 ± 11 years. 55% were female. Mean BMI was 29 ± 8kg/m2. Mean daily step-count was calculated for each patient over four time-windows: 60 days prior to surgery (preop), 42-49 days postop (6 weeks), 91-98 days postop (3 months), and 183-197 days postop (6 months). Spearman correlation coefficients and linear regression were used to assess the association between PROMs (HOOS-12, HOOS-Jr, and UCLA) and step-count. Patients were separated into three step-count levels: low (< 2500 steps/day), medium (2500-5500 steps/day), and high (> 5500 steps/day). Age > 65 years, BMI > 35 kg/m2, and sex were used for demographic comparisons. Post hoc analyses were performed using Welch's unequal variances t-tests, or Wilcoxon rank-sum tests, both with Bonferroni corrections, where appropriate when comparing between groups. Chi-squared analyses were also used when comparing categorical variables. UCLA correlated with step-count at all time-windows (p< 0.001). HOOS12-Function correlated with step-count preoperatively, at 6 weeks, and at 3 months (p< 0.001). High step-count individuals had improved UCLA scores compared to low step-count individuals preoperatively (Δ1.5, p< 0.001), at 6 weeks (Δ0.9, p< 0.001), at 3 months (Δ1.4, p< 0.001), and at 6 months (Δ1.4, p< 0.001). High step-count individuals had improved HOOS12-Function scores compared to low step-count individuals preoperatively (Δ9.6, p< 0.001), at 6 weeks (Δ5.3, p< 0.001), and at 3 months (Δ6.1, p< 0.001). Males had greater step-count at all time points (p< 0.001). Younger patients and low BMI patients had greater step-count across all time points (p< 0.001). High step-count improved PROMs scores compared to low step-count. Early post-operative step-count was significantly impacted by age, sex, and BMI. Generic recovery profiles may not be appropriate across diverse populations.

Some smokers switch away from smoking using e-cigarettes, but guidelines recommend trying approved medications first. We analyzed switching in adult smokers using JUUL by their recent history of quit attempts and use of smoking cessation medications. Participants were 8511 adult (21+) established smokers (at baseline), in which 50.3% are daily smokers, in a longitudinal observational study who completed a survey 12 months after first purchasing a JUUL Starter Kit. At baseline, participants reported attempts to quit smoking in the prior year and use of pharmacotherapy (nicotine replacement therapy [NRT] or prescription medication) in their most recent attempt. The outcomes were switching (self-reported no past-30-day smoking) and 50%+ reductions in cigarette consumption. Multivariable analyses were adjusted for baseline covariates. Two thirds of the participants had made a quit attempt in the year before purchasing JUUL. Overall, 59% [58%, 60%] had switched at 12 months. Switching was more likely in those who had used NRT and who attempted quitting without medication versus those who used prescription medications or made no quit attempt. In adjusted multivariable analyses, only making a past-year quit attempt (vs. not) was associated with higher odds of switching (OR =1.15 [1.04, 1.28]). Over 60% of dual users reduced cigarette consumption by ≥50%. These associations were largely similar in daily smokers. Twelve months after purchasing JUUL, almost all smokers reported either switching or reducing their smoking by 50%+, including those who had recently failed to quit smoking with approved pharmacotherapies. E-cigarettes provide an alternative route to abstinence from smoking for smokers with a history of cessation and cessation treatment failure.

Background:Mentorship is a key aspect of leadership development for orthopaedic surgeons, but there are few formalized mentorship programs in medical training. The individualized development plan (IDP) is a tool that potentially improves mentorship opportunities through identifying specific competency deficiencies and facilitating communication with mentors.Purpose:To assess the views of prospective orthopaedic surgery sports medicine fellows on the skills necessary for career development and the utility of an IDP for longitudinal career mentorship during a sports medicine fellowship.Study Design:Cross-sectional study.Methods:Candidates who interviewed for an orthopaedic surgery sports medicine fellowship voluntarily completed an anonymous IDP as well as a survey to assess their perceptions of the IDP tool to define their career goals and its use for longitudinal mentorship. The IDP included quantitative and qualitative responses for the self-assessment of multiple skill domains (general research, teaching, professional, interpersonal, leadership, and management) using a 5-point Likert scale (1 = needs improvement, 5 = highly proficient). Quantitative results were analyzed using analysis of variance and Student t test.Results:A total of 25 candidates completed the IDP and survey. The mean ± standard deviation composite score of all skill domains was 3.62 ± 0.91. The candidates’ greatest deficit was in grant writing (2.28 ± 0.94; P < .01), while their greatest strength was getting along with others (4.52 ± 0.65; P < .01). Candidates identified, as short-term goals, obtaining a fellowship training position, completion of research/academic projects, and improvement of surgical skills; their common long-term goals included having a role in an academic institution, professional society, and/or research and innovation environment. The majority of participants agreed that the IDP is a valuable tool to characterize career and personal goals (74%) and facilitate longitudinal fellowship mentorship (83.3%).Conclusion:The majority of candidates valued the IDP for their short- and long-term goals. Program implementation of an IDP could be beneficial in allowing trainees to effectively identify areas of weakness and strengths while facilitating efficient communication of these needs to mentors.